Provider Demographics
NPI:1548234867
Name:GREEN, GERALD (DO)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:
Last Name:GREEN
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 1:320 MIDDLETOWN BLVD
Mailing Address - Street 2:
Mailing Address - City:LANGHORNE
Mailing Address - State:PA
Mailing Address - Zip Code:19047-3204
Mailing Address - Country:US
Mailing Address - Phone:215-752-0382
Mailing Address - Fax:221-575-2480
Practice Address - Street 1:320 MIDDLETOWN BLVD
Practice Address - Street 2:
Practice Address - City:LANGHORNE
Practice Address - State:PA
Practice Address - Zip Code:19047-3204
Practice Address - Country:US
Practice Address - Phone:215-752-0382
Practice Address - Fax:221-575-2480
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS003032L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006143680004Medicaid
PAE64106Medicare UPIN