Provider Demographics
NPI:1699973420
Name:GREEN, DEMETRIS ALLEN SR (MD)
Entity type:Individual
Prefix:DR
First Name:DEMETRIS
Middle Name:ALLEN
Last Name:GREEN
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2646 S LOOP W
Mailing Address - Street 2:SUITE 440
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054-2665
Mailing Address - Country:US
Mailing Address - Phone:713-808-9658
Mailing Address - Fax:281-501-3075
Practice Address - Street 1:2646 S LOOP W
Practice Address - Street 2:SUITE 440
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-2665
Practice Address - Country:US
Practice Address - Phone:713-808-9658
Practice Address - Fax:281-501-3075
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2012-08-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXJ4168208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2817272Medicaid
TXTXB134244Medicare PIN