Provider Demographics
NPI:1639299738
Name:GREEN, LEONARD J (MD)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:J
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 710
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:IN
Mailing Address - Zip Code:47371-0710
Mailing Address - Country:US
Mailing Address - Phone:260-726-8822
Mailing Address - Fax:260-726-7857
Practice Address - Street 1:428 W VOTAW ST
Practice Address - Street 2:SUITE A
Practice Address - City:PORTLAND
Practice Address - State:IN
Practice Address - Zip Code:47371-1302
Practice Address - Country:US
Practice Address - Phone:260-726-8822
Practice Address - Fax:260-726-7857
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01027059A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100253720Medicaid
IN100253720Medicaid