Basic Information
| Provider Information | |||||||||
| NPI: | 1639525884 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1150 YOUNGS RD STE 104 | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142218096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166367990 | ||||||||
| FaxNumber: | 7166367993 | ||||||||
| Practice Location | |||||||||
| Address1: | 3950 E ROBINSON RD STE 207 | ||||||||
| Address2: | |||||||||
| City: | W AMHERST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142282044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7165641111 | ||||||||
| FaxNumber: | 7165641128 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2016 | ||||||||
| LastUpdateDate: | 07/22/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 300292 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.