Provider Demographics
NPI:1316052046
Name:GREEN, HOWARD (DPM)
Entity type:Individual
Prefix:
First Name:HOWARD
Middle Name:
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 1:580 W GERMANTOWN PIKE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PLYMOUTH MEETING
Mailing Address - State:PA
Mailing Address - Zip Code:19462
Mailing Address - Country:US
Mailing Address - Phone:610-825-7288
Mailing Address - Fax:610-828-8556
Practice Address - Street 1:580 W GERMANTOWN PIKE
Practice Address - Street 2:SUITE 100
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462
Practice Address - Country:US
Practice Address - Phone:610-828-7288
Practice Address - Fax:610-828-8556
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC002526L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0983890Medicaid
PA0048247000OtherKEYSTONE
PA50144OtherAETNA
PA0048247000OtherKEYSTONE
PA138128Medicare ID - Type Unspecified
PA50144OtherAETNA