Provider Demographics
NPI:1689182511
Name:GREEN, ERIC MELVIN
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:MELVIN
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2038 24TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-1030
Mailing Address - Country:US
Mailing Address - Phone:301-704-1270
Mailing Address - Fax:
Practice Address - Street 1:2038 24TH AVE. SE
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071
Practice Address - Country:US
Practice Address - Phone:301-704-1270
Practice Address - Fax:405-310-2367
Is Sole Proprietor?:No
Enumeration Date:2018-01-12
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator