Healthcare Provider Details

I. General information

NPI: 1851736037
Provider Name (Legal Business Name): WESLEY C GREEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2013
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 INSIGHT AVE
O FALLON IL
62269-2146
US

IV. Provider business mailing address

705 INSIGHT AVE
O FALLON IL
62269-2146
US

V. Phone/Fax

Practice location:
  • Phone: 618-738-0337
  • Fax:
Mailing address:
  • Phone: 618-391-1660
  • Fax: 618-861-6003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number2017006915
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036174940
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: