Provider Demographics
NPI:1750332698
Name:GREEN, CARLOS ERNESTO (OD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:ERNESTO
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 1:265 GOLDENROD ST
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-4708
Mailing Address - Country:US
Mailing Address - Phone:714-528-2750
Mailing Address - Fax:
Practice Address - Street 1:2117 E LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-4105
Practice Address - Country:US
Practice Address - Phone:714-776-8770
Practice Address - Fax:714-776-7710
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 8238 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0082380Medicaid
CASD0082380Medicaid
CAY4615Medicare ID - Type UnspecifiedMEDICARE PROVIDER