Provider Demographics
NPI:1386612414
Name:GREEN, JOHNNY BERT (MD)
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:BERT
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 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-302-2400
Mailing Address - Fax:208-302-2455
Practice Address - Street 1:1072 N LIBERTY STREET
Practice Address - Street 2:SUITE 201
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-302-2400
Practice Address - Fax:208-302-2455
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA35113208600000X, 208C00000X
IDM-11186208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1386612414Medicaid
ID1386612414Medicaid
AB09886Medicare ID - Type Unspecified