Healthcare Provider Details

I. General information

NPI: 1003928532
Provider Name (Legal Business Name): RUSSELL JOHN GREEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8751 N 117TH EAST AVE UNIT H
OWASSO OK
74055-2098
US

IV. Provider business mailing address

8751 N 117TH EAST AVE UNIT H
OWASSO OK
74055-2098
US

V. Phone/Fax

Practice location:
  • Phone: 918-609-1600
  • Fax: 918-609-1319
Mailing address:
  • Phone: 918-609-1600
  • Fax: 918-609-1319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number17587
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: