Healthcare Provider Details

I. General information

NPI: 1164635173
Provider Name (Legal Business Name): DOUGLAS ALLEN GREEN M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 11/21/2025
Certification Date: 11/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31700 TEMECULA PKWY
TEMECULA CA
92592-5896
US

IV. Provider business mailing address

PO BOX 2389
TEMECULA CA
92593-2389
US

V. Phone/Fax

Practice location:
  • Phone: 951-600-3811
  • Fax:
Mailing address:
  • Phone: 951-600-3811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number3992-320
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMC-207
License Number StateGU
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD-52680
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA100113
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberA100113
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA100113
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number16698C
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: