Basic Information
| Provider Information | |||||||||
| NPI: | 1932198249 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 496084 | ||||||||
| Address2: | |||||||||
| City: | REDDING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960496084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302410473 | ||||||||
| FaxNumber: | 5302293703 | ||||||||
| Practice Location | |||||||||
| Address1: | 612 G ST | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955011020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074443439 | ||||||||
| FaxNumber: | 7074443459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2005 | ||||||||
| LastUpdateDate: | 11/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0122X | G73342 | CA | Y | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00G733420 | 05 | CA | MEDICAID |