Individual
JOHNNY BERT GREEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1072 N LIBERTY STREET, SUITE 201, BOISE, ID 83704
(208) 302-2400
(208) 302-2455
Mailing address
3340 E GOLDSTONE WAY, MERIDIAN, ID 83642-1026
(208) 302-2400
(208) 302-2455
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
35113
WA
208C00000X
Colon & Rectal Surgery Physician
35113
WA
208C00000X
Colon & Rectal Surgery Physician
Primary
M-11186
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1386612414
—
ID
Enumeration date
03/14/2006
Last updated
11/15/2016
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