Provider Demographics
NPI:1609907732
Name:GREEN, ALAN ROBERT (MD, FAAAI)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:ROBERT
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD, FAAAI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 VERDUGO BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-1402
Mailing Address - Country:US
Mailing Address - Phone:818-790-5233
Mailing Address - Fax:818-790-8754
Practice Address - Street 1:1809 VERDUGO BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-1402
Practice Address - Country:US
Practice Address - Phone:818-790-5233
Practice Address - Fax:818-790-8754
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG28157174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG28157Medicare UPIN