Provider Demographics
NPI:1568486827
Name:GREEN, AMANDA LEIGH (MD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEIGH
Last Name:GREEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 CLARKSVILLE ST
Mailing Address - Street 2:STE 185
Mailing Address - City:PARIS
Mailing Address - State:TX
Mailing Address - Zip Code:75460-6097
Mailing Address - Country:US
Mailing Address - Phone:903-737-1476
Mailing Address - Fax:903-737-1553
Practice Address - Street 1:1055 CLARKSVILLE ST
Practice Address - Street 2:STE 185
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75460-6097
Practice Address - Country:US
Practice Address - Phone:903-783-7147
Practice Address - Fax:903-737-1553
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXL5638207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH38292Medicare UPIN
TX8F0708Medicare ID - Type Unspecified