Healthcare Provider Details

I. General information

NPI: 1982992145
Provider Name (Legal Business Name): DIANA ROSE GREEN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2011
Last Update Date: 07/27/2020
Certification Date: 07/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 NEVINS ST STE 205
BRIGHTON MA
02135-3514
US

IV. Provider business mailing address

800 WASHINGTON ST
BOSTON MA
02111-1552
US

V. Phone/Fax

Practice location:
  • Phone: 617-783-5050
  • Fax: 617-783-0734
Mailing address:
  • Phone: 617-636-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4858
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: