Healthcare Provider Details

I. General information

NPI: 1801896816
Provider Name (Legal Business Name): GARY A GREEN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2005
Last Update Date: 09/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 SHEPARD LN SUITE 102
FARMINGTON UT
84025-3936
US

IV. Provider business mailing address

670 SHEPARD LN SUITE 102
FARMINGTON UT
84025-3936
US

V. Phone/Fax

Practice location:
  • Phone: 801-451-7500
  • Fax: 801-451-6966
Mailing address:
  • Phone: 801-451-7500
  • Fax: 801-451-6966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number104878-0501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: