Provider Demographics
NPI:1245206705
Name:GREEN, ROLLIN M (MD)
Entity Type:Individual
Prefix:DR
First Name:ROLLIN
Middle Name:M
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 1:24411 HEALTH CENTER DR STE 520
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3633
Mailing Address - Country:US
Mailing Address - Phone:949-452-3841
Mailing Address - Fax:949-859-8937
Practice Address - Street 1:24012 CALLE DE LA PLATA STE 200
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-7624
Practice Address - Country:US
Practice Address - Phone:949-452-3841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-24
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYG23339207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
W13458Medicare ID - Type Unspecified
A41922Medicare UPIN