Provider Demographics
NPI:1932148509
Name:GREENE, JOHN ELBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ELBERT
Last Name:GREENE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:303 N CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2709
Mailing Address - Country:US
Mailing Address - Phone:386-226-4590
Mailing Address - Fax:386-226-3371
Practice Address - Street 1:311 N CLYDE MORRIS BLVD STE 480
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2766
Practice Address - Country:US
Practice Address - Phone:386-425-4199
Practice Address - Fax:386-425-4680
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME12921208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD65458Medicare UPIN
FL64522XMedicare ID - Type UnspecifiedSINGLE PHYSICIAN PRACTICE