Provider Demographics
NPI:1508509092
Name:GREEN, ALIA DEYIRA (MD)
Entity type:Individual
Prefix:
First Name:ALIA
Middle Name:DEYIRA
Last Name:GREEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ALIA
Other - Middle Name:DEYIRA
Other - Last Name:PIERRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:202 S SHADOW ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:FL
Mailing Address - Zip Code:32351-3343
Mailing Address - Country:US
Mailing Address - Phone:850-322-7094
Mailing Address - Fax:
Practice Address - Street 1:2626 CAPITAL MEDICAL BLVD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4402
Practice Address - Country:US
Practice Address - Phone:850-325-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-14
Last Update Date:2025-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-17218207Q00000X
390200000X
FLME171017207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program