Provider Demographics
NPI:1649264318
Name:GREENE, MALCOLM RICHARD (OD)
Entity type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:RICHARD
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 1:31 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-3473
Mailing Address - Country:US
Mailing Address - Phone:617-924-3343
Mailing Address - Fax:617-926-6634
Practice Address - Street 1:31 SPRING ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-3473
Practice Address - Country:US
Practice Address - Phone:617-924-3343
Practice Address - Fax:617-926-6634
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2219152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0306754Medicaid
MA0306754Medicaid