Provider Demographics
NPI:1336353135
Name:JOHN J GREEN DO PA
Entity Type:Organization
Organization Name:JOHN J GREEN DO PA
Other - Org Name:INTERNAL MEDICINE AND GENERAL PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:JUSTIN
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:239-332-4099
Mailing Address - Street 1:15880 SUMMERLIN RD
Mailing Address - Street 2:PMB 207
Mailing Address - City:FORT 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 AVENUE
Practice Address - Street 2:SUITE 104
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4336
Practice Address - Country:US
Practice Address - Phone:239-332-4099
Practice Address - Fax:239-332-4088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 8155207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK5010Medicare PIN
FLDA7641Medicare PIN