Provider Demographics
NPI:1558732735
Name:GREEN, LAWRENCE EZRA (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:EZRA
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 1:27 S CENTER ST
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-4147
Mailing Address - Country:US
Mailing Address - Phone:352-589-6500
Mailing Address - Fax:
Practice Address - Street 1:27 S CENTER ST
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-4147
Practice Address - Country:US
Practice Address - Phone:352-589-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME030276207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine