Provider Demographics
NPI:1609977511
Name:GREEN, WELDON D (MD)
Entity Type:Individual
Prefix:DR
First Name:WELDON
Middle Name:D
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 1:1001 US HIGHWAY 83 N
Mailing Address - Street 2:
Mailing Address - City:CHILDRESS
Mailing Address - State:TX
Mailing Address - Zip Code:79201-2322
Mailing Address - Country:US
Mailing Address - Phone:940-937-3636
Mailing Address - Fax:940-937-9644
Practice Address - Street 1:1001 HWY 83 N
Practice Address - Street 2:
Practice Address - City:CHILDRESS
Practice Address - State:TX
Practice Address - Zip Code:79201
Practice Address - Country:US
Practice Address - Phone:940-937-3636
Practice Address - Fax:940-937-9644
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6383207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8B4353OtherBLUE CROSS BLUE SHIELD
TX130206907Medicaid
B87993Medicare UPIN
TX130206907Medicaid