Provider Demographics
NPI:1154434447
Name:GREEN, CLARE A (DO)
Entity type:Individual
Prefix:
First Name:CLARE
Middle Name:A
Last Name:GREEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 SUPERIOR AVE
Mailing Address - Street 2:STE 200B
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3663
Mailing Address - Country:US
Mailing Address - Phone:949-791-3001
Mailing Address - Fax:949-791-3096
Practice Address - Street 1:510 SUPERIOR AVE
Practice Address - Street 2:STE 200B
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3663
Practice Address - Country:US
Practice Address - Phone:949-791-3001
Practice Address - Fax:949-791-3096
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO23355207Q00000X
CA20A11841207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286263Medicaid
OR286263Medicaid
CAGZ901ZMedicare PIN
OR138482Medicare PIN