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NPI Code Detail

MEDICARE: NATHAN GREEN O.D., P.C.

MEDICARE: NATHAN GREEN O.D., P.C.
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
1152W00000XOptometrist5340358-9934UT

General Provider Information

NPI Number : 1477735710
Entity Type Code : Organization
Provider Name (Legal Business Name) : NATHAN GREEN O.D., P.C.
Provider Business Mailing Address
First Line : 1818 S 300 W
Second Line :
City : SALT LAKE CITY
State : UT
Zip : 84115-1805
Country : US
Telephone Number : 801-485-9757
Fax Number : 801-485-8867
Provider Business Practice Location Address
First Line : 1818 S 300 W
Second Line :
City : SALT LAKE CITY
State : UT
Zip : 84115-1805
Country : US
Telephone Number : 801-485-9757
Fax Number : 801-485-8867
Authorized Official
Title or Position : PRESIDENT
Name : DR. NATHAN RAY GREEN
Credential : OD
Telephone Number : 801-485-9757
Provider Enumeration Date : 11/28/2007
Last Update Date : 11/28/2007

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