Provider Demographics
NPI:1134165566
Name:GREEN, MICHAEL LEWIS JR (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LEWIS
Last Name:GREEN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:900 JEROME ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3945
Mailing Address - Country:US
Mailing Address - Phone:817-720-9552
Mailing Address - Fax:817-921-1830
Practice Address - Street 1:900 JEROME ST
Practice Address - Street 2:SUITE 204
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3945
Practice Address - Country:US
Practice Address - Phone:817-720-9552
Practice Address - Fax:817-921-1830
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXL7736208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8S2322OtherBCBS
TX163670603Medicaid
TX163670602Medicaid
TX8S2322OtherBCBS
TXI01854Medicare UPIN
TX163670603Medicaid
TX8G0231Medicare PIN
TXP00271589Medicare PIN