=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568413011
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GERALD I GREEN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2006
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 540 MADISON OAK #520
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78258-3943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-490-0202
-----------------------------------------------------
Fax | 210-490-0648
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 540 MADISON OAK #520
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78258-3943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-490-0202
-----------------------------------------------------
Fax | 210-490-0648
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | D8539
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | D8539
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------