Basic Information
| Provider Information | |||||||||
| NPI: | 1285619650 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREENE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | DOUGLAS | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 908 NIAGARA FALLS BLVD | ||||||||
| Address2: | STE 208 | ||||||||
| City: | N TONAWANDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141202019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166923302 | ||||||||
| FaxNumber: | 7163323525 | ||||||||
| Practice Location | |||||||||
| Address1: | 5290 MILITARY RD | ||||||||
| Address2: | SUITE 8 | ||||||||
| City: | LEWISTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140921953 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162979379 | ||||||||
| FaxNumber: | 7162974638 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2005 | ||||||||
| LastUpdateDate: | 11/27/2009 | ||||||||
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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 | 207V00000X | 126103 | NY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 00743577 | 05 | NY | MEDICAID |