Healthcare Provider Details

I. General information

NPI: 1821371022
Provider Name (Legal Business Name): ERICK JOSEPH GREEN JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2011
Last Update Date: 09/26/2023
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 HERNDON AVE # 101
CLOVIS CA
93611-6101
US

IV. Provider business mailing address

7471 N FRESNO ST
FRESNO CA
93720-2457
US

V. Phone/Fax

Practice location:
  • Phone: 559-797-4315
  • Fax: 559-900-7952
Mailing address:
  • Phone: 559-436-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberA130378
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA130378
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: