Provider Demographics
NPI:1134129497
Name:GREEN, KATHRYN A (MD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:A
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 1:1442 N 31ST ST
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-3061
Mailing Address - Country:US
Mailing Address - Phone:920-452-1810
Mailing Address - Fax:
Practice Address - Street 1:1442 N 31ST ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3061
Practice Address - Country:US
Practice Address - Phone:920-452-1810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24165-020207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B53216Medicare UPIN
WI23112Medicare ID - Type Unspecified