Provider Demographics
NPI:1043531676
Name:GREEN, MACK (MD)
Entity Type:Individual
Prefix:
First Name:MACK
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:12277 APPLE VALLEY RD
Mailing Address - Street 2:PMB 288
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92308-1701
Mailing Address - Country:US
Mailing Address - Phone:760-956-5200
Mailing Address - Fax:760-669-0793
Practice Address - Street 1:16008 KAMANA RD
Practice Address - Street 2:SUITE 100
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-1376
Practice Address - Country:US
Practice Address - Phone:760-956-5200
Practice Address - Fax:760-669-0793
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2015-09-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA1259029207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine