Provider Demographics
NPI:1114060498
Name:LAWRENCE H GREEN, MD A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:LAWRENCE H GREEN, MD A MEDICAL CORPORATION
Other - Org Name:GREEN VISION CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:H
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-990-0300
Mailing Address - Street 1:16055 VENTURA BLVD
Mailing Address - Street 2:#630
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2601
Mailing Address - Country:US
Mailing Address - Phone:818-990-0300
Mailing Address - Fax:818-990-4854
Practice Address - Street 1:16055 VENTURA BLVD
Practice Address - Street 2:#630
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2601
Practice Address - Country:US
Practice Address - Phone:818-990-0300
Practice Address - Fax:818-990-4854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG26942207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW9201Medicare PIN
CA0189020001Medicare NSC