Provider Demographics
NPI:1114048162
Name:GREEN, BARRY SETH (OD)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:SETH
Last Name:GREEN
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 1:7147 BURNETT ST
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4349
Mailing Address - Country:US
Mailing Address - Phone:707-829-5440
Mailing Address - Fax:888-416-4393
Practice Address - Street 1:7147 BURNETT ST
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4349
Practice Address - Country:US
Practice Address - Phone:707-829-5440
Practice Address - Fax:888-416-4393
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9001T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP943ZMedicare PIN