Healthcare Provider Details

I. General information

NPI: 1952336752
Provider Name (Legal Business Name): LYDIA MARIE GREEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 09/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6033 W CENTURY BLVD STE 200
LOS ANGELES CA
90045-6440
US

IV. Provider business mailing address

2851 W 120TH ST STE E-134
HAWTHORNE CA
90250-3395
US

V. Phone/Fax

Practice location:
  • Phone: 323-691-1772
  • Fax:
Mailing address:
  • Phone: 323-691-1772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberA068297
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: