Provider Demographics
NPI:1477735710
Name:NATHAN GREEN O.D., P.C.
Entity Type:Organization
Organization Name:NATHAN GREEN O.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:801-485-9757
Mailing Address - Street 1:1818 S 300 W
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-1805
Mailing Address - Country:US
Mailing Address - Phone:801-485-9757
Mailing Address - Fax:801-485-8867
Practice Address - Street 1:1818 S 300 W
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-1805
Practice Address - Country:US
Practice Address - Phone:801-485-9757
Practice Address - Fax:801-485-8867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5340358-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU99203Medicare UPIN