Provider Demographics
NPI:1316193881
Name:GREEN, JONAS (MD, MPH)
Entity type:Individual
Prefix:
First Name:JONAS
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 BROXTON AVENUE
Mailing Address - Street 2:UCLA DIVISION OF GENERAL INTERNAL MEDICINE
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-2801
Mailing Address - Country:US
Mailing Address - Phone:310-794-0150
Mailing Address - Fax:
Practice Address - Street 1:911 BROXTON AVENUE
Practice Address - Street 2:UCLA DIVISION OF GENERAL INTERNAL MEDICINE
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-2801
Practice Address - Country:US
Practice Address - Phone:310-794-0150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-15
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA98048207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A980480Medicaid
CABE965ZMedicare PIN