Provider Demographics
NPI:1114039336
Name:GREENE, RICHARD ALAN (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ALAN
Last Name:GREENE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 A1A S
Mailing Address - Street 2:SUITE C2
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-2916
Mailing Address - Country:US
Mailing Address - Phone:904-471-8750
Mailing Address - Fax:904-471-5996
Practice Address - Street 1:2225 A1A S
Practice Address - Street 2:SUITE C2
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-2916
Practice Address - Country:US
Practice Address - Phone:904-471-8750
Practice Address - Fax:904-471-5996
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1648152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT85222Medicare UPIN
FL20139Medicare ID - Type Unspecified