Provider Demographics
NPI:1083839328
Name:GREEN, LORELLEN MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:LORELLEN
Middle Name:MARIE
Last Name:GREEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11500 BROOKSHIRE AVE
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-4917
Mailing Address - Country:US
Mailing Address - Phone:562-904-5000
Mailing Address - Fax:
Practice Address - Street 1:11500 BROOKSHIRE AVE
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-4917
Practice Address - Country:US
Practice Address - Phone:562-904-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA97548207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA97548AMedicare PIN
CAEO251ZMedicare PIN