Provider Demographics
NPI:1457616898
Name:GREENE, MATTHEW B (OD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:B
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 1:1119 E LAMAR ST
Mailing Address - Street 2:
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31709
Mailing Address - Country:US
Mailing Address - Phone:229-924-4022
Mailing Address - Fax:229-924-7133
Practice Address - Street 1:1119 E LAMAR ST
Practice Address - Street 2:
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31709
Practice Address - Country:US
Practice Address - Phone:229-924-4022
Practice Address - Fax:229-924-7133
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002701152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist