Healthcare Provider Details

I. General information

NPI: 1811098379
Provider Name (Legal Business Name): BRADLEY ALAN GREENE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3130 ALPINE RD SUITE 195
PORTOLA VALLEY CA
94028-7549
US

IV. Provider business mailing address

3130 ALPINE RD SUITE 195
PORTOLA VALLEY CA
94028-7549
US

V. Phone/Fax

Practice location:
  • Phone: 650-851-0155
  • Fax: 650-529-0929
Mailing address:
  • Phone: 650-851-0155
  • Fax: 650-529-0929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberA74002
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: