Provider Demographics
NPI:1417072190
Name:J DOUGLAS GREEN JR MD PA
Entity Type:Organization
Organization Name:J DOUGLAS GREEN JR MD PA
Other - Org Name:JACKSONVILLE HEARING & BALANCE INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OTOLARYNGOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:J
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:904-399-0350
Mailing Address - Street 1:10475 CENTURION PKWY N
Mailing Address - Street 2:SUITE 303
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256
Mailing Address - Country:US
Mailing Address - Phone:904-399-0350
Mailing Address - Fax:904-399-5914
Practice Address - Street 1:10475 CENTURION PKWY N
Practice Address - Street 2:SUITE 303
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256
Practice Address - Country:US
Practice Address - Phone:904-399-0350
Practice Address - Fax:904-399-5914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0058964207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & NeurotologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL371813100FLMedicaid
FL371813100FLMedicaid
FLE75228Medicare UPIN