Provider Demographics
NPI:1699738294
Name:GREEN, CRAIG ROGER (OD)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:ROGER
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 1:260 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:OH
Mailing Address - Zip Code:45640-1745
Mailing Address - Country:US
Mailing Address - Phone:740-286-5022
Mailing Address - Fax:740-286-7000
Practice Address - Street 1:260 E MAIN ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640-1745
Practice Address - Country:US
Practice Address - Phone:740-286-5022
Practice Address - Fax:740-286-7000
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4282/T1346152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0457400001OtherADMINISTAR
OH0862357Medicaid
OH0457400001OtherADMINISTAR
U42043Medicare UPIN