MEDICARE: MR. DANNY LATRELL 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	745	MS

General Provider Information

NPI Number	:	1982644597
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DANNY LATRELL GREEN O.D.

Provider Business Mailing Address
First Line	:	6030 WOODLEA RD
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39206-2143
Country	:	US
Telephone Number	:	601-922-9272
Fax Number	:	601-922-8252

Provider Business Practice Location Address
First Line	:	4253 ROBINSON ST
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39209-6530
Country	:	US
Telephone Number	:	601-922-9272
Fax Number	:

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

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	02/19/2019

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