Provider Demographics
NPI:1447412598
Name:GREEN, WALTER RUSSELL
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:RUSSELL
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5131 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78214-3219
Mailing Address - Country:US
Mailing Address - Phone:210-526-5213
Mailing Address - Fax:210-626-1191
Practice Address - Street 1:5131 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78214-3219
Practice Address - Country:US
Practice Address - Phone:210-526-5213
Practice Address - Fax:210-626-1191
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment