Provider Demographics
NPI:1700997251
Name:GREEN, LARRY H (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:H
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:16055 VENTURA BLVD
Mailing Address - Street 2:#630
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2601
Mailing Address - Country:US
Mailing Address - Phone:818-990-0300
Mailing Address - Fax:818-990-4854
Practice Address - Street 1:16055 VENTURA BLVD
Practice Address - Street 2:#630
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2601
Practice Address - Country:US
Practice Address - Phone:818-990-0300
Practice Address - Fax:818-990-4854
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-03-15
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Provider Licenses
StateLicense IDTaxonomies
CAG26942207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA43155Medicare UPIN
CAWG26942BMedicare PIN