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General NPI Number Information
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NPI Number | 1851979983
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Entity Type | Individual
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Provider Name | JOHNNY RICHARD GREEN JR. DO
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Gender | Male
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Dates
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Enumeration Date | 03/30/2021
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Last Update Date | 03/14/2025
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Provider Practice Location Address
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Address Line | 81 ED PERRY BLVD STE 107
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City | OXFORD
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State | MS
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Zip | 38655-3465
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Country | US
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Telephone | 662-636-5290
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Fax |
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Provider Business Mailing Address
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Address Line | 965 RIDGE LAKE BLVD
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City | MEMPHIS
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State | TN
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Zip | 38120-9401
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Country | US
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Telephone | 901-227-4692
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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 | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | T-4329
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 33279
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License Number State | MS
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