Provider Demographics
NPI:1801821780
Name:GREEN, RODDY D (MD)
Entity Type:Individual
Prefix:
First Name:RODDY
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 1:100 BOURLAND RD STE 100
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-3591
Mailing Address - Country:US
Mailing Address - Phone:817-379-5100
Mailing Address - Fax:817-379-0479
Practice Address - Street 1:100 BOURLAND RD STE 100
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-3591
Practice Address - Country:US
Practice Address - Phone:817-379-5100
Practice Address - Fax:817-379-0479
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6054207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX170258105Medicaid
TX170258101Medicaid
TX170258102Medicaid
TX170258102Medicaid
TX8D0811Medicare PIN
TXI12118Medicare UPIN
TXTXB101145Medicare PIN