Healthcare Provider Details

I. General information

NPI: 1356568968
Provider Name (Legal Business Name): KIMBERLY GREEN-MAYER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 12/28/2020
Certification Date: 12/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6940 MAIN ST
KEW GARDENS HILLS NY
11367-1723
US

IV. Provider business mailing address

40 DEVON RD
GREAT NECK NY
11023-1659
US

V. Phone/Fax

Practice location:
  • Phone: 718-268-5282
  • Fax: 718-261-4359
Mailing address:
  • Phone: 347-262-0056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number236212
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: