Healthcare Provider Details

I. General information

NPI: 1568454155
Provider Name (Legal Business Name): GARY HOWARD GREENE O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 01/20/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 N 16TH ST STE 160
PHOENIX AZ
85016-5348
US

IV. Provider business mailing address

2626 E VISTA DR
PHOENIX AZ
85032-4939
US

V. Phone/Fax

Practice location:
  • Phone: 602-277-5007
  • Fax: 480-505-0922
Mailing address:
  • Phone: 480-296-4646
  • Fax: 480-505-0922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberAZ0810
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberAZ0810
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: