Provider Demographics
NPI:1053335844
Name:GREEN, DAVID A (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:A
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 1:9696 SKILLMAN ST
Mailing Address - Street 2:SUITE 285
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-8264
Mailing Address - Country:US
Mailing Address - Phone:214-348-7611
Mailing Address - Fax:214-348-0129
Practice Address - Street 1:9696 SKILLMAN ST
Practice Address - Street 2:SUITE 285
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-8264
Practice Address - Country:US
Practice Address - Phone:214-348-7611
Practice Address - Fax:214-348-0129
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXK9073207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX043103305Medicaid
TX8B7349Medicare ID - Type Unspecified
TXE80124Medicare UPIN
TX8K4944Medicare PIN