Basic Information
Provider Information | |||||||||
NPI: | 1629003538 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GREEN | ||||||||
FirstName: | PRESTON | ||||||||
MiddleName: | T | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13575 NW 1ST LN STE 20 | ||||||||
Address2: |   | ||||||||
City: | NEWBERRY | ||||||||
State: | FL | ||||||||
PostalCode: | 326693735 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3523325755 | ||||||||
FaxNumber: | 8559641157 | ||||||||
Practice Location | |||||||||
Address1: | 350 NW 76TH DR | ||||||||
Address2: | SUITE B | ||||||||
City: | GAINESVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 326071593 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3523325755 | ||||||||
FaxNumber: | 8668879246 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/11/2006 | ||||||||
LastUpdateDate: | 11/17/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/17/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | ME45509 | FL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 045242400 | 05 | FL |   | MEDICAID |