Provider Demographics
NPI:1932198249
Name:GREEN, ROBERT M JR (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:GREEN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 496084
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96049-6084
Mailing Address - Country:US
Mailing Address - Phone:530-241-0473
Mailing Address - Fax:530-229-3703
Practice Address - Street 1:612 G ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-1020
Practice Address - Country:US
Practice Address - Phone:707-444-3439
Practice Address - Fax:707-444-3459
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG733422086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G733420Medicaid
E25117Medicare UPIN
CA00G733420Medicaid