Provider Demographics
NPI:1366415804
Name:GREEN, JEFFREY A (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 HOSPITAL PLAZA
Mailing Address - Street 2:SUITE 502
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-3602
Mailing Address - Country:US
Mailing Address - Phone:203-348-7410
Mailing Address - Fax:203-961-8488
Practice Address - Street 1:29 HOSPITAL PLAZA
Practice Address - Street 2:SUITE 502
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-3602
Practice Address - Country:US
Practice Address - Phone:203-348-7410
Practice Address - Fax:203-961-8488
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT041904207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTI02073Medicare UPIN
CT060001577Medicare ID - Type Unspecified
CT001419044Medicaid