Healthcare Provider Details

I. General information

NPI: 1013172477
Provider Name (Legal Business Name): HARRY MIGUEL GREEN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2008
Last Update Date: 06/09/2022
Certification Date: 06/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4641 MISSOURI FLAT RD
PLACERVILLE CA
95667-6816
US

IV. Provider business mailing address

4327 GOLDEN CENTER DR
PLACERVILLE CA
95667-6287
US

V. Phone/Fax

Practice location:
  • Phone: 510-642-0749
  • Fax:
Mailing address:
  • Phone: 530-621-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number13578T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: