Provider Demographics
NPI:1982992145
Name:GREEN, DIANA ROSE (OD)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:ROSE
Last Name:GREEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1552
Mailing Address - Country:US
Mailing Address - Phone:617-636-5000
Mailing Address - Fax:
Practice Address - Street 1:11 NEVINS ST STE 205
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-3514
Practice Address - Country:US
Practice Address - Phone:617-783-5050
Practice Address - Fax:617-783-0734
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4858152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110090817/AMedicaid
MA110090817/AMedicaid