Provider Demographics
NPI:1083000855
Name:GREEN, JAMES (DO)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2493 S WILDCAT WAY UNIT B
Mailing Address - Street 2:
Mailing Address - City:WOODS CROSS
Mailing Address - State:UT
Mailing Address - Zip Code:84010-8292
Mailing Address - Country:US
Mailing Address - Phone:801-693-3020
Mailing Address - Fax:
Practice Address - Street 1:1322 3RD ST SE
Practice Address - Street 2:SUITE 240
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372
Practice Address - Country:US
Practice Address - Phone:253-697-1420
Practice Address - Fax:253-697-1439
Is Sole Proprietor?:No
Enumeration Date:2015-04-08
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10748354-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT3007238Medicaid