Provider Demographics
NPI:1730415928
Name:GREEN, STEPHANIE (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 MEADOW ST FL 1
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1719
Mailing Address - Country:US
Mailing Address - Phone:203-946-8181
Mailing Address - Fax:
Practice Address - Street 1:54 MEADOW ST FL 1
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1719
Practice Address - Country:US
Practice Address - Phone:203-946-8181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-23
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT038231207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010010547CT01OtherBLUE CROSS