Provider Demographics
NPI:1154345254
Name:GREEN, GARY ALAN (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:ALAN
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:881 ALMA REAL DR STE 101
Mailing Address - Street 2:
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-3792
Mailing Address - Country:US
Mailing Address - Phone:310-829-8923
Mailing Address - Fax:424-212-5936
Practice Address - Street 1:881 ALMA REAL DR STE 101
Practice Address - Street 2:
Practice Address - City:PACIFIC PALISADES
Practice Address - State:CA
Practice Address - Zip Code:90272-3792
Practice Address - Country:US
Practice Address - Phone:310-829-8923
Practice Address - Fax:424-212-5936
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG63969207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G639690Medicaid
CAE50484Medicare UPIN
CA00G639690Medicaid
CAWG63969EMedicare PIN