Provider Demographics
NPI:1912050980
Name:GREEN, KELLY DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:DOUGLAS
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143-4802
Mailing Address - Country:US
Mailing Address - Phone:501-278-2800
Mailing Address - Fax:501-278-3073
Practice Address - Street 1:2900 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-4802
Practice Address - Country:US
Practice Address - Phone:501-278-2800
Practice Address - Fax:501-278-3073
Is Sole Proprietor?:No
Enumeration Date:2007-01-20
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002010422174400000X
ARE-9196207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1159308OtherCAQH
1159308OtherCAQH
G66209Medicare UPIN
00103738Medicare ID - Type Unspecified