Provider Demographics
NPI:1871011064
Name:GREEN, ERIC DEMOND
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:DEMOND
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 1:90 PINE ST
Mailing Address - Street 2:
Mailing Address - City:SHEPHERD
Mailing Address - State:TX
Mailing Address - Zip Code:77371-6597
Mailing Address - Country:US
Mailing Address - Phone:713-882-0779
Mailing Address - Fax:
Practice Address - Street 1:90 PINE ST
Practice Address - Street 2:
Practice Address - City:SHEPHERD
Practice Address - State:TX
Practice Address - Zip Code:77371
Practice Address - Country:US
Practice Address - Phone:713-882-0779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11271506172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty