Provider Demographics
NPI:1366193310
Name:GREEN, KODY (CNP)
Entity type:Individual
Prefix:
First Name:KODY
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3595 COLUMBUS RD
Mailing Address - Street 2:
Mailing Address - City:CENTERBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43011-7088
Mailing Address - Country:US
Mailing Address - Phone:740-625-6234
Mailing Address - Fax:740-625-5806
Practice Address - Street 1:3595 COLUMBUS RD
Practice Address - Street 2:
Practice Address - City:CENTERBURG
Practice Address - State:OH
Practice Address - Zip Code:43011-7088
Practice Address - Country:US
Practice Address - Phone:740-625-6234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-11
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0030515207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine