Individual
DR. TYSON ELLIS GREEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.P.M.
Contact information
Practice address
1747 IMPERIAL BLVD, LAKE CHARLES, LA 70605-5362
(337) 721-7236
(337) 721-7237
Mailing address
501 DR MICHAEL DEBAKEY DR, LAKE CHARLES, LA 70601-5724
(337) 312-8258
(337) 312-6711
Taxonomy
Speciality
Code
Description
License number
State
213ES0103X
Foot & Ankle Surgery Podiatrist
Primary
DPM200024
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1805033
—
LA
Enumeration date
11/30/2008
Last updated
01/30/2017
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