Provider Demographics
NPI:1518387174
Name:GREENE, GREGORY (DO)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:GREENE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 CLAGUE RD STE 3201
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-1588
Mailing Address - Country:US
Mailing Address - Phone:440-250-2070
Mailing Address - Fax:
Practice Address - Street 1:960 CLAGUE RD STE 3201
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-1588
Practice Address - Country:US
Practice Address - Phone:440-250-2070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-22
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH012826207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH34012826OtherMEDICAL LICENSE