Provider Demographics
NPI:1902874704
Name:GREEN, DAVID STEVEN (MD)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:STEVEN
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 1:10987 CATTAIL PT
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-9367
Mailing Address - Country:US
Mailing Address - Phone:318-797-8777
Mailing Address - Fax:
Practice Address - Street 1:7829 YOUREE DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5505
Practice Address - Country:US
Practice Address - Phone:318-797-8777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023098174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1494429Medicaid
LA1494429Medicaid
LA5H767Medicare ID - Type Unspecified