Provider Demographics
NPI:1477538296
Name:WHITE GREEN, ANDREA LYNETTE (MD)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:LYNETTE
Last Name:WHITE GREEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:LYNETTE
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5 TWIN SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:DALWORTHINGTON GARDENS
Mailing Address - State:TX
Mailing Address - Zip Code:76016-4027
Mailing Address - Country:US
Mailing Address - Phone:817-467-0527
Mailing Address - Fax:817-467-0573
Practice Address - Street 1:5 TWIN SPRINGS DR
Practice Address - Street 2:
Practice Address - City:DALWORTHINGTON GARDENS
Practice Address - State:TX
Practice Address - Zip Code:76016-4027
Practice Address - Country:US
Practice Address - Phone:817-467-0527
Practice Address - Fax:817-467-0573
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27978207P00000X
CO43981207P00000X
TXG9826207P00000X
IL036153315207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO58137351Medicaid
TX158826103Medicaid
P00421202OtherRAILROAD MEDICARE
P00421202OtherRAILROAD MEDICARE
COB53212Medicare UPIN
TX158826103Medicaid