Provider Demographics
NPI:1487240446
Name:GREEN, LAVARRE (OTR)
Entity type:Individual
Prefix:
First Name:LAVARRE
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9939 FREDERICKSBURG RD APT 1815
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-4158
Mailing Address - Country:US
Mailing Address - Phone:504-300-7425
Mailing Address - Fax:
Practice Address - Street 1:9939 FREDERICKSBURG RD APT 1815
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-4158
Practice Address - Country:US
Practice Address - Phone:504-300-7425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-14
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX119090208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation