Provider Demographics
NPI:1194857136
Name:GREEN, LAWRENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 PLAZA SOUTH ST # 297
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-4750
Mailing Address - Country:US
Mailing Address - Phone:918-456-8989
Mailing Address - Fax:918-457-5010
Practice Address - Street 1:23507 EAST RIVERVIEW DRIVE
Practice Address - Street 2:
Practice Address - City:COOKSON
Practice Address - State:OK
Practice Address - Zip Code:74427-2471
Practice Address - Country:US
Practice Address - Phone:918-456-8989
Practice Address - Fax:918-457-5010
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2024-03-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK9260207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100093200DMedicaid
OK100093200DMedicaid
OKOKB5459Medicare PIN
OKD05217Medicare UPIN