Healthcare Provider Details

I. General information

NPI: 1104889344
Provider Name (Legal Business Name): GERMAINE V. GREEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 03/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 SOUTH CENTRAL AVENUE #100
GLENDALE CA
91204
US

IV. Provider business mailing address

1500 SOUTH CENTRAL AVENUE #100
GLENDALE CA
91204
US

V. Phone/Fax

Practice location:
  • Phone: 818-367-7980
  • Fax: 818-637-7985
Mailing address:
  • Phone: 818-367-7980
  • Fax: 818-637-7985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG54334
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: