Provider Demographics
NPI:1982607487
Name:GREEN, KIRK DENNIS (DO)
Entity Type:Individual
Prefix:DR
First Name:KIRK
Middle Name:DENNIS
Last Name:GREEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N 17TH ST
Mailing Address - Street 2:
Mailing Address - City:KEOKUK
Mailing Address - State:IA
Mailing Address - Zip Code:52632-3452
Mailing Address - Country:US
Mailing Address - Phone:319-524-5734
Mailing Address - Fax:319-524-5758
Practice Address - Street 1:400 N 17TH ST
Practice Address - Street 2:
Practice Address - City:KEOKUK
Practice Address - State:IA
Practice Address - Zip Code:52632-3452
Practice Address - Country:US
Practice Address - Phone:319-524-5734
Practice Address - Fax:319-524-5758
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01737207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2308999Medicaid
54388OtherBLUE CROSS BLUE SHIELD
IA2308999Medicaid
54388OtherBLUE CROSS BLUE SHIELD