Healthcare Provider Details

I. General information

NPI: 1720108525
Provider Name (Legal Business Name): ALLEN H GREEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11860 WILSHIRE BLVD #200
LOS ANGELES CA
90025-6613
US

IV. Provider business mailing address

11860 WILSHIRE BLVD #200
LOS ANGELES CA
90025-6613
US

V. Phone/Fax

Practice location:
  • Phone: 310-445-6600
  • Fax: 310-445-6601
Mailing address:
  • Phone: 310-445-6600
  • Fax: 310-445-6601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberG63445
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberG63445
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG063445
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: