Provider Demographics
NPI:1689669798
Name:GREENE, RAYMOND KARL (OD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:KARL
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 1:850 W IRONWOOD DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4903
Mailing Address - Country:US
Mailing Address - Phone:208-765-2020
Mailing Address - Fax:208-765-1460
Practice Address - Street 1:850 W IRONWOOD DR
Practice Address - Street 2:SUITE 104
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4903
Practice Address - Country:US
Practice Address - Phone:208-765-2020
Practice Address - Fax:208-765-1460
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID845152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002691400Medicaid
ID002691400Medicaid
IDU28432Medicare UPIN
ID1593301Medicare PIN