Provider Demographics
NPI:1689947509
Name:MARY KELLY GREEN MD PLLC
Entity Type:Organization
Organization Name:MARY KELLY GREEN MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:K
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:830-693-5868
Mailing Address - Street 1:204 GATEWAY N
Mailing Address - Street 2:SUITE A
Mailing Address - City:MARBLE FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:78654-6361
Mailing Address - Country:US
Mailing Address - Phone:830-698-5868
Mailing Address - Fax:830-798-8017
Practice Address - Street 1:204 GATEWAY N
Practice Address - Street 2:SUITE A
Practice Address - City:MARBLE FALLS
Practice Address - State:TX
Practice Address - Zip Code:78654-6361
Practice Address - Country:US
Practice Address - Phone:830-698-5868
Practice Address - Fax:830-798-8017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-23
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX152W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty