Provider Demographics
NPI:1255318572
Name:GREEN, JOHN JUSTIN (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JUSTIN
Last Name:GREEN
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Gender:M
Credentials:DO
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Mailing Address - Street 1:15880 SUMMERLIN RD
Mailing Address - Street 2:PMB 207
Mailing Address - City:FT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-9612
Mailing Address - Country:US
Mailing Address - Phone:239-332-4099
Mailing Address - Fax:239-332-4088
Practice Address - Street 1:14131 METROPOLIS AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4455
Practice Address - Country:US
Practice Address - Phone:239-332-4099
Practice Address - Fax:239-332-4088
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2012-03-09
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Provider Licenses
StateLicense IDTaxonomies
FLOS8155207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00071073Medicare PIN
FL58689AMedicare PIN