Provider Demographics
NPI:1285970830
Name:GREEN, STEPHEN TYLER (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:TYLER
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 1:1101 MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3147
Mailing Address - Country:US
Mailing Address - Phone:504-349-1297
Mailing Address - Fax:
Practice Address - Street 1:1111 MEDICAL CENTER BLVD STE N707
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3158
Practice Address - Country:US
Practice Address - Phone:504-934-8550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-28
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA327285207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2412914Medicaid