Provider Demographics
NPI:1215917968
Name:GREEN, ROGER ELLIOTT (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:ELLIOTT
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:657 CAMINO DE LOS MARES
Mailing Address - Street 2:SUITE 242
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2826
Mailing Address - Country:US
Mailing Address - Phone:949-496-6066
Mailing Address - Fax:949-496-6497
Practice Address - Street 1:657 CAMINO DE LOS MARES
Practice Address - Street 2:SUITE 242
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673
Practice Address - Country:US
Practice Address - Phone:949-496-6066
Practice Address - Fax:949-496-6497
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC36384207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13458AMedicare ID - Type Unspecified
A36245Medicare UPIN