Provider Demographics
NPI:1568454155
Name:GREENE, GARY HOWARD (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:HOWARD
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 1:2626 E VISTA DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-4939
Mailing Address - Country:US
Mailing Address - Phone:480-296-4646
Mailing Address - Fax:480-505-0922
Practice Address - Street 1:4201 N 16TH ST STE 160
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5348
Practice Address - Country:US
Practice Address - Phone:602-277-5007
Practice Address - Fax:480-505-0922
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ0810152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0179560OtherBLUE CROSS BLUE SHIELD
AZP00276390OtherRAILROAD MEDICARE
AZ137085OtherAHCCS
AZ137085Medicaid
AZAZ0810OtherEYE MED
AZAZ0179560OtherBLUE CROSS BLUE SHIELD
AZT84113Medicare UPIN
AZZOD810Medicare PIN