Provider Demographics
NPI:1699770495
Name:GREEN, KEVIN J (O D)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:J
Last Name:GREEN
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2038 MONUMENT AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-2708
Mailing Address - Country:US
Mailing Address - Phone:804-353-3555
Mailing Address - Fax:804-353-9630
Practice Address - Street 1:2038 MONUMENT AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220-2708
Practice Address - Country:US
Practice Address - Phone:804-353-3555
Practice Address - Fax:804-353-9630
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618-000057152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA012848001OtherDME POINT OF SERVICE
VA89-2028-1Medicaid
586486OtherUS HEALTHCARE
22-00047OtherUNITED HEALTHCARE
VA038113OtherANTHEM
VAU21508Medicare UPIN
586486OtherUS HEALTHCARE