Provider Demographics
NPI:1740678770
Name:DEMETRIS A. GREEN, SR. MD PA
Entity type:Organization
Organization Name:DEMETRIS A. GREEN, SR. MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
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:713-808-9658
Mailing Address - Street 1:2646 S LOOP W
Mailing Address - Street 2:SUITE 220
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054-2665
Mailing Address - Country:US
Mailing Address - Phone:713-808-9658
Mailing Address - Fax:281-501-3075
Practice Address - Street 1:2646 S LOOP W
Practice Address - Street 2:SUITE 220
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-2665
Practice Address - Country:US
Practice Address - Phone:713-808-9658
Practice Address - Fax:281-501-3075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-29
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty