MEDICARE: KELLY PATRICK 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	T03284	MO
2	152W00000X	Optometrist	6702T	TX

General Provider Information

NPI Number	:	1649230947
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY PATRICK GREEN O.D.

Provider Business Mailing Address
First Line	:	11801 SPRINGS HEAD LOOP
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78717-4418
Country	:	US
Telephone Number	:	512-331-0211
Fax Number	:

Provider Business Practice Location Address
First Line	:	7437 BURNET RD
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78757-2244
Country	:	US
Telephone Number	:	512-451-7562
Fax Number	:	512-451-7951

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

Provider Enumeration Date	:	03/23/2006
Last Update Date	:	07/08/2007

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