Provider Demographics
NPI:1558360875
Name:GREEN, KRISTINA E (DPM)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:E
Last Name:GREEN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44000 W 12 MILE RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-2644
Mailing Address - Country:US
Mailing Address - Phone:248-347-8233
Mailing Address - Fax:248-347-8174
Practice Address - Street 1:44000 W 12 MILE RD
Practice Address - Street 2:SUITE 111
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-2644
Practice Address - Country:US
Practice Address - Phone:248-347-8233
Practice Address - Fax:248-347-8174
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003381213E00000X
MI5901002628213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2501804Medicaid
OH0697670001OtherDURABLE MEDICAL EQUIPMENT
OH9349281Medicare PIN
OH4147732Medicare PIN
OH2501804Medicaid
OH0697670001Medicare NSC
OH4147731Medicare PIN
V02521Medicare UPIN
OHP00167166Medicare PIN