Provider Demographics
NPI:1366551202
Name:GREEN, THOMAS LEONARD (DO)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:LEONARD
Last Name:GREEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:688 FRENCHTOWN ROAD
Mailing Address - Street 2:
Mailing Address - City:EAST GREENWICH
Mailing Address - State:RI
Mailing Address - Zip Code:02818
Mailing Address - Country:US
Mailing Address - Phone:401-885-5193
Mailing Address - Fax:401-885-1466
Practice Address - Street 1:688 FRENCHTOWN ROAD
Practice Address - Street 2:
Practice Address - City:EAST GREENWICH
Practice Address - State:RI
Practice Address - Zip Code:02818
Practice Address - Country:US
Practice Address - Phone:401-885-5193
Practice Address - Fax:401-885-1466
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDO302207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9003021Medicaid
RI9003021Medicaid