Provider Demographics
NPI:1821371022
Name:GREEN, ERICK JOSEPH JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ERICK
Middle Name:JOSEPH
Last Name:GREEN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7471 N FRESNO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2457
Mailing Address - Country:US
Mailing Address - Phone:559-436-4500
Mailing Address - Fax:
Practice Address - Street 1:2021 HERNDON AVE # 101
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-6101
Practice Address - Country:US
Practice Address - Phone:559-797-4315
Practice Address - Fax:559-900-7952
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA130378207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA124156Medicare PIN
CACA109622Medicare PIN