Provider Demographics
NPI:1760437818
Name:GREENE, KARL PHILLIP (OD)
Entity Type:Individual
Prefix:
First Name:KARL
Middle Name:PHILLIP
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:PO BOX 399
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47375-0399
Mailing Address - Country:US
Mailing Address - Phone:765-962-2020
Mailing Address - Fax:765-966-2975
Practice Address - Street 1:2045 VIRGINIA AVENUE
Practice Address - Street 2:
Practice Address - City:CONNERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47331
Practice Address - Country:US
Practice Address - Phone:765-825-0660
Practice Address - Fax:765-825-3075
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001373A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100279430Medicaid
IN100279430Medicaid
INP00924313Medicare PIN