Provider Demographics
NPI:1598787988
Name:GREEN, ANDREW B (DPM)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:B
Last Name:GREEN
Suffix:
Gender:M
Credentials:DPM
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Mailing Address - Street 1:1890 LPGA BLVD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-7130
Mailing Address - Country:US
Mailing Address - Phone:386-274-3336
Mailing Address - Fax:386-274-3660
Practice Address - Street 1:1890 LPGA BLVD
Practice Address - Street 2:SUITE 230
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-7130
Practice Address - Country:US
Practice Address - Phone:386-274-3336
Practice Address - Fax:386-274-3660
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2008-05-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLPO2932213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL340272000Medicaid
FLE7317ZMedicare PIN
U89952Medicare UPIN
FL4380280001Medicare NSC