Provider Demographics
NPI:1932342094
Name:GREEN, DANIEL LUTHER III (IDMT)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:LUTHER
Last Name:GREEN
Suffix:III
Gender:M
Credentials:IDMT
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Other - Credentials:
Mailing Address - Street 1:854 BAYFIELD WAY APT 302
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-4620
Mailing Address - Country:US
Mailing Address - Phone:707-365-6924
Mailing Address - Fax:
Practice Address - Street 1:1 NORAD RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80914-6001
Practice Address - Country:US
Practice Address - Phone:719-474-3862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-19
Last Update Date:2009-04-19
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians