Healthcare Provider Details

I. General information

NPI: 1457618977
Provider Name (Legal Business Name): AMANDA BETH GREEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2012
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13652 CANTARA ST MOB 6
PANORAMA CITY CA
91402-5423
US

IV. Provider business mailing address

13652 CANTARA ST MOB 6
PANORAMA CITY CA
91402-5423
US

V. Phone/Fax

Practice location:
  • Phone: 818-350-6223
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA136605
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: