Provider Demographics
NPI:1013063171
Name:GREEN, MELISSA SUE
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:SUE
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 SE 33RD ST
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-4158
Mailing Address - Country:US
Mailing Address - Phone:239-823-3998
Mailing Address - Fax:239-596-8688
Practice Address - Street 1:614 SE 33RD ST
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-4158
Practice Address - Country:US
Practice Address - Phone:239-823-3998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC00003235152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL410040922Medicare ID - Type UnspecifiedMEDICARE NUMBER
FLU76228Medicare UPIN