Provider Demographics
NPI:1518949106
Name:GREEN, JOHN WILLOCK (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WILLOCK
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:561 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-1410
Mailing Address - Country:US
Mailing Address - Phone:740-615-2141
Mailing Address - Fax:740-615-2142
Practice Address - Street 1:561 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-1410
Practice Address - Country:US
Practice Address - Phone:740-615-2141
Practice Address - Fax:740-615-2142
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.081269207Q00000X
OH35081269208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2411947Medicaid
OH4107625Medicare PIN