Provider Demographics
NPI:1972557858
Name:GREEN, LANNY (MD)
Entity type:Individual
Prefix:DR
First Name:LANNY
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:23077 GREENFIELD RD
Mailing Address - Street 2:144
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-3709
Mailing Address - Country:US
Mailing Address - Phone:248-569-6120
Mailing Address - Fax:248-569-6134
Practice Address - Street 1:23077 GREENFIELD RD
Practice Address - Street 2:144
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3709
Practice Address - Country:US
Practice Address - Phone:248-569-6120
Practice Address - Fax:248-569-6134
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301077362207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4289294Medicaid
MIN26450002Medicare ID - Type Unspecified
MI4289294Medicaid