Provider Demographics
NPI:1326015934
Name:GREENE, DAVID S (OD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:S
Last Name:GREENE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:D
Other - Middle Name:S
Other - Last Name:GREENE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:120 VISION DR
Mailing Address - Street 2:
Mailing Address - City:CORNELIA
Mailing Address - State:GA
Mailing Address - Zip Code:30531-5737
Mailing Address - Country:US
Mailing Address - Phone:706-776-2025
Mailing Address - Fax:706-778-4540
Practice Address - Street 1:120 VISION DR
Practice Address - Street 2:
Practice Address - City:CORNELIA
Practice Address - State:GA
Practice Address - Zip Code:30531-5737
Practice Address - Country:US
Practice Address - Phone:706-776-2025
Practice Address - Fax:706-778-4540
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000982152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00361215BMedicaid
U22297Medicare UPIN