1669609459 NPI number — DEMETRIS ALLEN GREEN MD

Table of content: (NPI 1669609459)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669609459 NPI number — DEMETRIS ALLEN GREEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEMETRIS ALLEN GREEN MD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669609459
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/22/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8299 CAMBRIDGE ST APT 1203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77054-3141
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-383-9003
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10610 FONDREN RD
Provider Second Line Business Practice Location Address:
STE 124
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77096-5422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-981-5167
Provider Business Practice Location Address Fax Number:
713-981-5553
Provider Enumeration Date:
06/18/2009

Additional Information

Authorized Official

Authorized Official Last Name:
GREEN
Authorized Official First Name:
DEMETRIS
Authorized Official Middle Name:
ALLEN
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
713-383-9003

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  J4168 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 613884700 . This is a "US DEPARTMENT OF LABOR" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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