Provider Demographics
NPI:1497078620
Name:GREEN-DATHORNE, JELITA ANN (OD)
Entity Type:Individual
Prefix:
First Name:JELITA
Middle Name:ANN
Last Name:GREEN-DATHORNE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2636 S LOOP W
Mailing Address - Street 2:STE 500
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054-2953
Mailing Address - Country:US
Mailing Address - Phone:281-354-1538
Mailing Address - Fax:281-354-1733
Practice Address - Street 1:2636 S LOOP W
Practice Address - Street 2:STE 500
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-2953
Practice Address - Country:US
Practice Address - Phone:713-790-0513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-02
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX07460TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX263864945OtherEIN