Healthcare Provider Details

I. General information

NPI: 1992711600
Provider Name (Legal Business Name): WILLIAM FREDERICK GREEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: WILLIAM FREDERICK GREEN JR. MD

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 STANFORD DR NE
ALBUQUERQUE NM
87106-3727
US

IV. Provider business mailing address

2211 LOMAS BLVD NE MSC10 5590
ALBUQUERQUE NM
87131-0001
US

V. Phone/Fax

Practice location:
  • Phone: 505-255-1108
  • Fax:
Mailing address:
  • Phone: 505-272-2345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number81-56
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number81-56
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: