Provider Demographics
NPI:1386806479
Name:GREEN, DALLIS. LOUIS (MD)
Entity type:Individual
Prefix:
First Name:DALLIS.
Middle Name:LOUIS
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 1:1431 W NINE MILE RD UNIT 11304
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32534-5373
Mailing Address - Country:US
Mailing Address - Phone:850-529-5542
Mailing Address - Fax:
Practice Address - Street 1:1531 OLDE MILL CREEK DR
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-2320
Practice Address - Country:US
Practice Address - Phone:504-858-6857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAN/A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery