MEDICARE: EUGENE 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
1	152W00000X	Optometrist	OPT7673TPL	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134274780
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EUGENE GREEN O.D.

Provider Business Mailing Address
First Line	:	876 S NORTON AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90005-3656
Country	:	US
Telephone Number	:	323-731-2474
Fax Number	:	323-731-9408

Provider Business Practice Location Address
First Line	:	1818 S WESTERN AVE
Second Line	:	STE.101
City	:	LOS ANGELES
State	:	CA
Zip	:	90006-5807
Country	:	US
Telephone Number	:	323-731-2474
Fax Number	:	323-731-9408

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2007
Last Update Date	:	07/08/2007

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Directions to “ EUGENE GREEN O.D.” Practice Location

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