Provider Demographics
NPI:1134658362
Name:GREEN, NICOLA (MD, PHD, MPH)
Entity Type:Individual
Prefix:
First Name:NICOLA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:MD, PHD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7750 EAST ROSELAND DR
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037
Mailing Address - Country:US
Mailing Address - Phone:858-775-4117
Mailing Address - Fax:858-459-0802
Practice Address - Street 1:7750 ROSELAND DR
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-4015
Practice Address - Country:US
Practice Address - Phone:858-775-4117
Practice Address - Fax:858-459-0802
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55506207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine