Provider Demographics
NPI:1225141393
Name:GREEN, STEVEN A (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:A
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5651 COPLEY DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-7903
Mailing Address - Country:US
Mailing Address - Phone:858-262-6666
Mailing Address - Fax:
Practice Address - Street 1:5651 COPLEY DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111
Practice Address - Country:US
Practice Address - Phone:858-262-6666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG58182207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G581820Medicaid
CAWG58182AMedicare ID - Type Unspecified
CA00G581820Medicaid