=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184709917
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN ROBERT GREEN III MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2006
-----------------------------------------------------
Last Update Date | 04/23/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8300 FLOYD CURL DR FL 3
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78229-3931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-450-9300
-----------------------------------------------------
Fax | 210-450-6023
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8300 FLOYD CURL DR FL 3
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78229-3931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-450-9300
-----------------------------------------------------
Fax | 210-450-6023
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | Q8494
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207XX0005X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
-----------------------------------------------------
License Number | Q8494
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------