Provider Demographics
NPI:1689223661
Name:GREEN, SAM JR (JD)
Entity Type:Individual
Prefix:MR
First Name:SAM
Middle Name:
Last Name:GREEN
Suffix:JR
Gender:M
Credentials:JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2924 GENERAL OGDEN ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70118-2317
Mailing Address - Country:US
Mailing Address - Phone:504-994-5286
Mailing Address - Fax:
Practice Address - Street 1:2601 TULANE AVE STE 300
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-7499
Practice Address - Country:US
Practice Address - Phone:504-570-6120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator