Provider Demographics
NPI:1134274780
Name:GREEN, EUGENE (OD)
Entity type:Individual
Prefix:
First Name:EUGENE
Middle Name:
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 1:876 S NORTON AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90005-3656
Mailing Address - Country:US
Mailing Address - Phone:323-731-2474
Mailing Address - Fax:323-731-9408
Practice Address - Street 1:1818 S WESTERN AVE
Practice Address - Street 2:STE.101
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-5807
Practice Address - Country:US
Practice Address - Phone:323-731-2474
Practice Address - Fax:323-731-9408
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT7673TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0076731Medicaid
CASD007630Medicaid
CAOP7673Medicare ID - Type Unspecified
CAOP7673AMedicare ID - Type Unspecified
CASD0076731Medicaid