Provider Demographics
NPI:1457054934
Name:GREEN, BRYCE ALLEN (DO)
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:ALLEN
Last Name:GREEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 DOROTHY LN
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59105-2615
Mailing Address - Country:US
Mailing Address - Phone:605-391-3047
Mailing Address - Fax:
Practice Address - Street 1:1324 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-4543
Practice Address - Country:US
Practice Address - Phone:863-687-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-23
Last Update Date:2023-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program