Provider Demographics
NPI:1184619132
Name:GREEN, RICHARD S (OD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:S
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 1:13210 SE 240TH ST
Mailing Address - Street 2:SUITE C-2
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98042-5182
Mailing Address - Country:US
Mailing Address - Phone:253-631-1530
Mailing Address - Fax:253-631-5262
Practice Address - Street 1:13210 SE 240TH ST
Practice Address - Street 2:SUITE C-2
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98042-5182
Practice Address - Country:US
Practice Address - Phone:253-631-1530
Practice Address - Fax:253-631-5262
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-15
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1648TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2001857Medicaid
WA2001857Medicaid
WAT01614Medicare UPIN