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General NPI Number Information
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NPI Number | 1124027644
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Entity Type | Individual
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Provider Name | JUSTIN B. GREEN D.P.M.
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Gender | Male
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Dates
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Enumeration Date | 07/18/2005
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2309 E MAIN ST SUITE 201
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City | NEW IBERIA
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State | LA
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Zip | 70560-4046
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Country | US
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Telephone | 337-364-8878
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Fax | 337-364-8380
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Provider Business Mailing Address
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Address Line | 2309 E MAIN ST SUITE 201
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City | NEW IBERIA
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State | LA
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Zip | 70560-4046
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Country | US
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Telephone | 337-560-5543
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | PD324R
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License Number State | LA
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