Provider Demographics
NPI:1568487049
Name:GREEN, DAVID (PT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26932 OSO PKWY
Mailing Address - Street 2:SUITE 260
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-5815
Mailing Address - Country:US
Mailing Address - Phone:949-582-8800
Mailing Address - Fax:949-582-5127
Practice Address - Street 1:26932 OSO PKWY
Practice Address - Street 2:SUITE 260
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-5815
Practice Address - Country:US
Practice Address - Phone:949-582-8800
Practice Address - Fax:949-582-5127
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT9145204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT9145AMedicare ID - Type Unspecified