Provider Demographics
NPI:1518205889
Name:GREEN, DAN WILLIAM (MD)
Entity Type:Individual
Prefix:MR
First Name:DAN
Middle Name:WILLIAM
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 1:800 WEST FIRST ST.
Mailing Address - Street 2:SUITE 3004
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90012
Mailing Address - Country:US
Mailing Address - Phone:213-617-9686
Mailing Address - Fax:213-617-7117
Practice Address - Street 1:800 WEST FIRST ST.
Practice Address - Street 2:SUITE 3004
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012
Practice Address - Country:US
Practice Address - Phone:213-617-9686
Practice Address - Fax:213-617-7117
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-22
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC22916207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine