Provider Demographics
NPI:1730131202
Name:GREEN, THEODORE F (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:F
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TED
Other - Middle Name:
Other - Last Name:WELLS-GREEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:9886 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DAMASCUS
Mailing Address - State:MD
Mailing Address - Zip Code:20872-3002
Mailing Address - Country:US
Mailing Address - Phone:301-368-3660
Mailing Address - Fax:301-368-3652
Practice Address - Street 1:9886 MAIN ST
Practice Address - Street 2:
Practice Address - City:DAMASCUS
Practice Address - State:MD
Practice Address - Zip Code:20872-3002
Practice Address - Country:US
Practice Address - Phone:301-368-3660
Practice Address - Fax:301-368-3652
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD43196208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics