Healthcare Provider Details

I. General information

NPI: 1639525884
Provider Name (Legal Business Name): JUSTIN M GREEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2016
Last Update Date: 07/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 E ROBINSON RD STE 207
W AMHERST NY
14228-2044
US

IV. Provider business mailing address

1150 YOUNGS RD STE 104
WILLIAMSVILLE NY
14221-8096
US

V. Phone/Fax

Practice location:
  • Phone: 716-564-1111
  • Fax: 716-564-1128
Mailing address:
  • Phone: 716-636-7990
  • Fax: 716-636-7993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number300292
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: