Provider Demographics
NPI:1225091085
Name:GREEN, MARY T (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:T
Last Name:GREEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:6624 FANNIN ST
Mailing Address - Street 2:SUITE 2105
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2312
Mailing Address - Country:US
Mailing Address - Phone:713-791-9494
Mailing Address - Fax:713-874-0170
Practice Address - Street 1:6624 FANNIN ST
Practice Address - Street 2:SUITE 2105
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2312
Practice Address - Country:US
Practice Address - Phone:713-791-9494
Practice Address - Fax:713-874-0170
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXG5114207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX128017403Medicaid
TX128017403Medicaid
TXB62649Medicare UPIN
TX89440JMedicare ID - Type Unspecified