Provider Demographics
NPI:1912906033
Name:GREEN, HENRY B (DPM)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:B
Last Name:GREEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 SANDUSKY ST STE A
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-3120
Mailing Address - Country:US
Mailing Address - Phone:419-666-5299
Mailing Address - Fax:419-666-9762
Practice Address - Street 1:1021 SANDUSKY ST STE A
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551
Practice Address - Country:US
Practice Address - Phone:419-666-5299
Practice Address - Fax:419-666-9762
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36001483213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0697670001OtherDURABLE MEDICAL EQUIPMENT
OH0123806Medicaid
OH0013885Medicare PIN
OH0013884Medicare PIN
OH480030518Medicare PIN
OH9349282Medicare PIN
OH9349281Medicare PIN
OHT80340Medicare UPIN
OH0123806Medicaid