Provider Demographics
NPI:1689665101
Name:GREEN, GREGORY CHAD (OD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:CHAD
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 1:1401 US HIGHWAY 80 W
Mailing Address - Street 2:
Mailing Address - City:DEMOPOLIS
Mailing Address - State:AL
Mailing Address - Zip Code:36732-4127
Mailing Address - Country:US
Mailing Address - Phone:334-289-0466
Mailing Address - Fax:334-289-5588
Practice Address - Street 1:1401 US HIGHWAY 80 W
Practice Address - Street 2:
Practice Address - City:DEMOPOLIS
Practice Address - State:AL
Practice Address - Zip Code:36732-4127
Practice Address - Country:US
Practice Address - Phone:334-289-0466
Practice Address - Fax:334-289-5588
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS773TA219152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL5259550001OtherPALMETTO BUTLER OFFICE
AL51526697OtherBCBS OF ALABAMA
AL009958385Medicaid
AL009958395Medicaid
AL5259550002OtherPALMETTO DEMOPOLIS OFFICE
AL51522197OtherBCBS OF ALABAMA
ALP00220332OtherRAILROAD MEDICARE
ALP00220332OtherRAILROAD MEDICARE
AL5259550002OtherPALMETTO DEMOPOLIS OFFICE
AL009958395Medicaid