Provider Demographics
NPI:1386735264
Name:GREEN, JEFFRY ALAN (OD)
Entity type:Individual
Prefix:DR
First Name:JEFFRY
Middle Name:ALAN
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 1:2522 COLBY AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201
Mailing Address - Country:US
Mailing Address - Phone:425-252-1231
Mailing Address - Fax:425-257-9881
Practice Address - Street 1:2522 COLBY AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201
Practice Address - Country:US
Practice Address - Phone:425-252-1231
Practice Address - Fax:425-257-9881
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWA1713TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2020634Medicaid
WAGAB02477Medicare ID - Type Unspecified
WA2020634Medicaid