Provider Demographics
NPI:1801896816
Name:GREEN, GARY A (DPM)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:A
Last Name:GREEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
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Mailing Address - Street 1:670 SHEPARD LN
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FARMINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84025-3936
Mailing Address - Country:US
Mailing Address - Phone:801-451-7500
Mailing Address - Fax:801-451-6966
Practice Address - Street 1:670 SHEPARD LN
Practice Address - Street 2:SUITE 102
Practice Address - City:FARMINGTON
Practice Address - State:UT
Practice Address - Zip Code:84025-3936
Practice Address - Country:US
Practice Address - Phone:801-451-7500
Practice Address - Fax:801-451-6966
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-01
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT104878-0501213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T39921Medicare UPIN
000004291Medicare ID - Type Unspecified