Provider Demographics
NPI:1649462144
Name:GREEN, ABE (MD)
Entity type:Individual
Prefix:
First Name:ABE
Middle Name:
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 1:2080 CENTURY PARK E
Mailing Address - Street 2:SUITE #1410
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90067-2001
Mailing Address - Country:US
Mailing Address - Phone:310-282-8202
Mailing Address - Fax:310-553-9103
Practice Address - Street 1:2080 CENTURY PARK E
Practice Address - Street 2:SUITE #1410
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-2001
Practice Address - Country:US
Practice Address - Phone:310-282-8202
Practice Address - Fax:310-553-9103
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-17
Last Update Date:2010-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48234207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G482340Medicaid
CA00G482340Medicaid
G48234AMedicare PIN