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NPI Code Detail

MEDICARE: JUSTIN GREEN

MEDICARE: JUSTIN GREEN
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1208600000XSurgery Physician4568SD

General Provider Information

NPI Number : 1114966462
Entity Type Code : Individual
Provider Name (Legal Business Name) : JUSTIN GREEN
Provider Business Mailing Address
First Line : 3917 WEST RD
Second Line :
City : LOS ALAMOS
State : NM
Zip : 87544-2275
Country : US
Telephone Number : 505-661-8900
Fax Number : 505-661-8916
Provider Business Practice Location Address
First Line : 3917 WEST RD STE A
Second Line :
City : LOS ALAMOS
State : NM
Zip : 87544-2292
Country : US
Telephone Number : 505-661-8900
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/05/2006
Last Update Date : 09/27/2024

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Directions to “ JUSTIN GREEN ” Practice Location

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