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NPI Code Detail

MEDICARE: DR. GORDON C GREEN O.D.

MEDICARE: DR. GORDON C 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
1152W00000XOptometrist18003063BIN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
111478959OTHERINCAQH PROVIDER ID

General Provider Information

NPI Number : 1063401107
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. GORDON C GREEN O.D.
Provider Business Mailing Address
First Line : 421 CHESTNUT ST
Second Line :
City : EVANSVILLE
State : IN
Zip : 47713-1227
Country : US
Telephone Number : 812-490-3937
Fax Number : 812-426-9880
Provider Business Practice Location Address
First Line : 421 CHESTNUT ST
Second Line :
City : EVANSVILLE
State : IN
Zip : 47713-1227
Country : US
Telephone Number : 812-490-3937
Fax Number : 812-426-9880
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/20/2005
Last Update Date : 01/28/2016

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Directions to “ DR. GORDON C GREEN O.D.” Practice Location

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