Provider Demographics
NPI:1336638238
Name:GREEN, ALEXANDER (DPM)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 W TENNESSEE AVE
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-6509
Mailing Address - Country:US
Mailing Address - Phone:865-482-1788
Mailing Address - Fax:865-482-1789
Practice Address - Street 1:170 W TENNESSEE AVE
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-6509
Practice Address - Country:US
Practice Address - Phone:865-482-1788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPM897213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6277909OtherBCBST
TNDPM897OtherTN PODIATRY BOARD
TNQ068463Medicaid
TNFG0373035OtherDEA