Basic Information
| Provider Information | |||||||||
| NPI: | 1467801399 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | SIMONE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4005 HIGH RESORT BLVD SE | ||||||||
| Address2: | |||||||||
| City: | RIO RANCHO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871245906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054626000 | ||||||||
| FaxNumber: | 5054628686 | ||||||||
| Practice Location | |||||||||
| Address1: | 4005 HIGH RESORT BLVD SE | ||||||||
| Address2: | |||||||||
| City: | RIO RANCHO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871245906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054626000 | ||||||||
| FaxNumber: | 5054628686 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2016 | ||||||||
| LastUpdateDate: | 07/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 07/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD2019-0128 | NM | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.