MEDICARE: DR. HARRY MIGUEL GREEN O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	13578T	CA

General Provider Information

NPI Number	:	1013172477
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HARRY MIGUEL GREEN O.D.

Provider Business Mailing Address
First Line	:	4327 GOLDEN CENTER DR
Second Line	:
City	:	PLACERVILLE
State	:	CA
Zip	:	95667-6287
Country	:	US
Telephone Number	:	530-621-7700
Fax Number	:

Provider Business Practice Location Address
First Line	:	4641 MISSOURI FLAT RD
Second Line	:
City	:	PLACERVILLE
State	:	CA
Zip	:	95667-6816
Country	:	US
Telephone Number	:	510-642-0749
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2008
Last Update Date	:	06/09/2022

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