Healthcare Provider Details

I. General information

NPI: 1306997499
Provider Name (Legal Business Name): JOHN A GREEN III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 11/26/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 JUEGO CT
SANTA FE NM
87508
US

IV. Provider business mailing address

3 JUEGO CT
SANTA FE NM
87508
US

V. Phone/Fax

Practice location:
  • Phone: 503-722-4270
  • Fax: 503-722-4450
Mailing address:
  • Phone: 503-722-4270
  • Fax: 503-722-4450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD12292
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: