Provider Demographics
NPI:1720108525
Name:GREEN, ALLEN H (MD)
Entity Type:Individual
Prefix:DR
First Name:ALLEN
Middle Name:H
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 1:11860 WILSHIRE BLVD
Mailing Address - Street 2:#200
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-6613
Mailing Address - Country:US
Mailing Address - Phone:310-445-6600
Mailing Address - Fax:310-445-6601
Practice Address - Street 1:11860 WILSHIRE BLVD
Practice Address - Street 2:#200
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-6613
Practice Address - Country:US
Practice Address - Phone:310-445-6600
Practice Address - Fax:310-445-6601
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG063445207Q00000X
CAG63445207KA0200X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABG0714142OtherDEA
CAE07527Medicare UPIN