Provider Demographics
NPI:1689603045
Name:GREEN, WILLIAM THOMAS (OD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:THOMAS
Last Name:GREEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1335 SOUTHGATE PKWY
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43725-3015
Mailing Address - Country:US
Mailing Address - Phone:740-439-1098
Mailing Address - Fax:740-439-3165
Practice Address - Street 1:1335 SOUTHGATE PKWY
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43725-3015
Practice Address - Country:US
Practice Address - Phone:740-439-1098
Practice Address - Fax:740-439-3165
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3120/T800152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH452082001OtherADMINASTAR FEDERAL DMERC
OH9321631OtherMEDICARE GROUP NUMBER
OH410047823OtherRAILROAD MEDICARE
OH0354674/6566685Medicaid
OH9321631OtherMEDICARE GROUP NUMBER
OHT80824Medicare UPIN