Provider Demographics
NPI:1528035318
Name:GREEN, HAL LESLIE (MD)
Entity Type:Individual
Prefix:
First Name:HAL
Middle Name:LESLIE
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4102 24TH ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410
Mailing Address - Country:US
Mailing Address - Phone:806-795-6428
Mailing Address - Fax:806-795-3654
Practice Address - Street 1:4102 24TH ST
Practice Address - Street 2:SUITE 302
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410
Practice Address - Country:US
Practice Address - Phone:806-795-6428
Practice Address - Fax:806-795-3654
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXC8522207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110594201Medicaid
TX00F402Medicare ID - Type Unspecified
TX110594201Medicaid