Provider Demographics
NPI:1881707388
Name:GREEN, CORI (MD)
Entity type:Individual
Prefix:DR
First Name:CORI
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 1:525 E 68TH ST # 139
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-4870
Mailing Address - Country:US
Mailing Address - Phone:212-746-0921
Mailing Address - Fax:
Practice Address - Street 1:525 E 68TH ST # 139
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-4870
Practice Address - Country:US
Practice Address - Phone:212-746-0921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2018-12-18
Deactivation Date:2015-07-13
Deactivation Code:
Reactivation Date:2015-08-31
Provider Licenses
StateLicense IDTaxonomies
NY240316208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY131623978Medicaid