Provider Demographics
NPI:1467554220
Name:GREEN, EDWARD III (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:GREEN
Suffix:III
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 1:1040 ELM AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-3264
Mailing Address - Country:US
Mailing Address - Phone:562-591-4444
Mailing Address - Fax:562-436-7350
Practice Address - Street 1:1040 ELM AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-3264
Practice Address - Country:US
Practice Address - Phone:562-591-4444
Practice Address - Fax:562-436-7350
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71869174400000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA71869OtherCA LICENSE
CA00A718690Medicaid
CO0226020002Medicare NSC
CAWA71869AMedicare PIN
CAA71869OtherCA LICENSE
CA00A718690Medicaid