Provider Demographics
NPI:1669609459
Name:DEMETRIS ALLEN GREEN MD
Entity type:Organization
Organization Name:DEMETRIS ALLEN GREEN MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DEMETRIS
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:713-383-9003
Mailing Address - Street 1:8299 CAMBRIDGE ST APT 1203
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054-3141
Mailing Address - Country:US
Mailing Address - Phone:713-383-9003
Mailing Address - Fax:
Practice Address - Street 1:10610 FONDREN RD
Practice Address - Street 2:STE 124
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77096-5422
Practice Address - Country:US
Practice Address - Phone:713-981-5167
Practice Address - Fax:713-981-5553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-18
Last Update Date:2009-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4168208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX613884700OtherUS DEPARTMENT OF LABOR