Provider Demographics
NPI:1831943844
Name:GREEN, OLIN DAVID JR
Entity type:Individual
Prefix:
First Name:OLIN
Middle Name:DAVID
Last Name:GREEN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 CROSS LANES DR
Mailing Address - Street 2:
Mailing Address - City:NITRO
Mailing Address - State:WV
Mailing Address - Zip Code:25143-1007
Mailing Address - Country:US
Mailing Address - Phone:314-791-1667
Mailing Address - Fax:
Practice Address - Street 1:142 CROSS LANES DR
Practice Address - Street 2:
Practice Address - City:NITRO
Practice Address - State:WV
Practice Address - Zip Code:25143-1007
Practice Address - Country:US
Practice Address - Phone:304-769-8484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-16
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty