Provider Demographics
NPI:1598742827
Name:GREEN, GLENN D (OD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:D
Last Name:GREEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3882 N FOXTAIL RD
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-0264
Mailing Address - Country:US
Mailing Address - Phone:360-739-6887
Mailing Address - Fax:208-457-7008
Practice Address - Street 1:3882 N FOXTAIL RD
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-0264
Practice Address - Country:US
Practice Address - Phone:360-739-6887
Practice Address - Fax:208-457-7008
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001910152W00000X
IDODP-100616152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA03118OtherREGENCE OF WA
WA0078676OtherDEPT OF LABOR & INDUSTRIE
WA2022267Medicaid
WA410040896OtherRAILROAD MEDICARE
WA431510001OtherGROUP HEALTH
WA0513660001Medicare NSC