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General NPI Number Information
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NPI Number | 1649230947
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Entity Type | Individual
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Provider Name | KELLY PATRICK GREEN O.D.
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Gender | Male
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Dates
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Enumeration Date | 03/23/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 7437 BURNET RD
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City | AUSTIN
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State | TX
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Zip | 78757-2244
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Country | US
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Telephone | 512-451-7562
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Fax | 512-451-7951
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Provider Business Mailing Address
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Address Line | 11801 SPRINGS HEAD LOOP
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City | AUSTIN
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State | TX
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Zip | 78717-4418
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Country | US
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Telephone | 512-331-0211
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | T03284
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 6702T
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License Number State | TX
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