Provider Demographics
NPI:1124226410
Name:GREEN, OTHA JR (PT)
Entity Type:Individual
Prefix:MR
First Name:OTHA
Middle Name:
Last Name:GREEN
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23029 CENTRAL PR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78255-2114
Mailing Address - Country:US
Mailing Address - Phone:210-698-3672
Mailing Address - Fax:
Practice Address - Street 1:23029 CENTRAL PR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78255-2114
Practice Address - Country:US
Practice Address - Phone:210-698-3672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1032621225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist