MEDICARE: DR. KEVIN J 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	0618-000057	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	012848001	OTHER	VA	DME POINT OF SERVICE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	586486	OTHER		US HEALTHCARE
4	22-00047	OTHER		UNITED HEALTHCARE
5	038113	OTHER	VA	ANTHEM

General Provider Information

NPI Number	:	1699770495
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEVIN J GREEN O. D.

Provider Business Mailing Address
First Line	:	2038 MONUMENT AVE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23220-2708
Country	:	US
Telephone Number	:	804-353-3555
Fax Number	:	804-353-9630

Provider Business Practice Location Address
First Line	:	2038 MONUMENT AVE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23220-2708
Country	:	US
Telephone Number	:	804-353-3555
Fax Number	:	804-353-9630

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

Provider Enumeration Date	:	06/17/2005
Last Update Date	:	04/28/2011

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