Provider Demographics
NPI:1912994328
Name:GREEN, GLENN J (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:J
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 1:450 GIDNEY AVE
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-3116
Mailing Address - Country:US
Mailing Address - Phone:845-562-1100
Mailing Address - Fax:845-562-7762
Practice Address - Street 1:450 GIDNEY AVE
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-3116
Practice Address - Country:US
Practice Address - Phone:845-562-1100
Practice Address - Fax:845-562-1162
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY149190207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY119190 1OtherOPTHALMOLOGIST RETINA
NY149190OtherOPTHALMOLOGIST RETINA
NY00718525Medicaid
NY119190 1OtherOPTHALMOLOGIST RETINA
NY149190OtherOPTHALMOLOGIST RETINA