Provider Demographics
NPI:1124027644
Name:GREEN, JUSTIN B (DPM)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:B
Last Name:GREEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2309 E MAIN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70560-4046
Mailing Address - Country:US
Mailing Address - Phone:337-560-5543
Mailing Address - Fax:
Practice Address - Street 1:2309 E MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70560-4046
Practice Address - Country:US
Practice Address - Phone:337-364-8878
Practice Address - Fax:337-364-8380
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPD324R213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1462462Medicaid
LA2223526OtherFIRST HEALTH
LAPD324ROtherSTATE LICENSE #
LA7714575OtherAETNA
LA5233550001Medicare ID - Type UnspecifiedPALMETTO GBA
LA7714575OtherAETNA
LAPD324ROtherSTATE LICENSE #
U94364Medicare UPIN