Provider Demographics
NPI:1851736037
Name:GREEN, WESLEY C (MD)
Entity type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:C
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 1:1 WHITFIELD LN
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63124-1838
Mailing Address - Country:US
Mailing Address - Phone:920-450-9133
Mailing Address - Fax:
Practice Address - Street 1:705 INSIGHT AVE
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-2146
Practice Address - Country:US
Practice Address - Phone:618-738-0337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036174940207W00000X
MO2017006915207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200043195Medicaid