Provider Demographics
NPI:1669460796
Name:GREEN, TRAVIS C (MD)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:C
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 1:2922 QUAIL OAK ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-1819
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9600 DATAPOINT DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-2028
Practice Address - Country:US
Practice Address - Phone:210-892-3700
Practice Address - Fax:210-617-4692
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2007-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE2584207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E21516Medicare UPIN
81P529Medicare ID - Type Unspecified