Healthcare Provider Details

I. General information

NPI: 1376650002
Provider Name (Legal Business Name): JAMES GREEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 08/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1631 HOSPITAL DR # 150
SANTA FE NM
87505
US

IV. Provider business mailing address

1631 HOSPITAL DR # 150
SANTA FE NM
87505-4728
US

V. Phone/Fax

Practice location:
  • Phone: 505-988-2215
  • Fax: 505-984-0373
Mailing address:
  • Phone: 505-988-2215
  • Fax: 505-984-0373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number89-205
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: