Provider Demographics
NPI:1932127560
Name:GREEN, HARRY LEE (MD)
Entity Type:Individual
Prefix:
First Name:HARRY
Middle Name:LEE
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 1:10781 LINDBROOK DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-3128
Mailing Address - Country:US
Mailing Address - Phone:310-474-4024
Mailing Address - Fax:
Practice Address - Street 1:10781 LINDBROOK DR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-3128
Practice Address - Country:US
Practice Address - Phone:310-474-4024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC18302207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C183020Medicaid
CAWC18302AMedicare PIN
CA00C183020Medicaid