Provider Demographics
NPI:1871590166
Name:GREEN, DOUGLASS W (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLASS
Middle Name:W
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:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0009
Mailing Address - Country:US
Mailing Address - Phone:423-857-2066
Mailing Address - Fax:423-857-2070
Practice Address - Street 1:1 MEDICAL PARK BLVD
Practice Address - Street 2:SUITE 450W
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7430
Practice Address - Country:US
Practice Address - Phone:423-968-3713
Practice Address - Fax:423-968-7352
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN015559207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3037797OtherBC
VA6016502Medicaid
VA082790OtherANTHEM
TN103I118141Medicare PIN
TN3037797OtherBC
3011095Medicare ID - Type Unspecified