Provider Demographics
NPI:1598740375
Name:GREEN, VERNON GARY (OD)
Entity Type:Individual
Prefix:
First Name:VERNON
Middle Name:GARY
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:PO BOX 490
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65402-0490
Mailing Address - Country:US
Mailing Address - Phone:573-364-6300
Mailing Address - Fax:573-341-5058
Practice Address - Street 1:1211 HAUCK DR
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-4900
Practice Address - Country:US
Practice Address - Phone:573-364-6300
Practice Address - Fax:573-341-5058
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02294152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T42546Medicare UPIN