Provider Demographics
NPI:1174522775
Name:GREEN, SHARON M (OD)
Entity type:Individual
Prefix:DR
First Name:SHARON
Middle Name:M
Last Name:GREEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:SHARON
Other - Middle Name:A
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:3111 W. 6TH
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-3101
Mailing Address - Country:US
Mailing Address - Phone:785-479-2020
Mailing Address - Fax:785-749-2323
Practice Address - Street 1:3111 W 6TH ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049-3101
Practice Address - Country:US
Practice Address - Phone:785-841-5288
Practice Address - Fax:785-749-2323
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2011-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1382-3152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100219780AMedicaid
KSU42215Medicare UPIN
KS017158Medicare ID - Type Unspecified
KS017158Medicare PIN
KS100219780AMedicaid