Healthcare Provider Details

I. General information

NPI: 1467491266
Provider Name (Legal Business Name): JOHN GREEN III D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 06/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6333 HIGHWAY 49 SUITE 7 ACHIEVE MEDICAL WEIGHT LOSS
HATTIESBURG MS
39401-3132
US

IV. Provider business mailing address

4925 GUILFORD FOREST DR SW
ATLANTA GA
30331-9005
US

V. Phone/Fax

Practice location:
  • Phone: 601-255-5326
  • Fax:
Mailing address:
  • Phone: 404-691-6149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number056998
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS008848L
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number21492
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: