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General NPI Number Information
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NPI Number | 1124102108
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Entity Type | Individual
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Provider Name | GARY M. GREEN MD
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Gender | Male
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Dates
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Enumeration Date | 10/25/2006
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Last Update Date | 09/25/2019
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Provider Practice Location Address
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Address Line | 34 MARK WEST SPRINGS RD FL 3
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City | SANTA ROSA
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State | CA
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Zip | 95403
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Country | US
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Telephone | 707-573-5234
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Fax | 707-573-5438
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Provider Business Mailing Address
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Address Line | 325 DISTEL CIR
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City | LOS ALTOS
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State | CA
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Zip | 94022-1408
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Country | US
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Telephone | 707-573-5234
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Fax | 707-573-5438
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RI0200X
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Taxonomy Name | Infectious Disease Physician
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License Number | G80599
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License Number State | CA
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