Provider Demographics
NPI:1811074875
Name:GREEN, GEORGE ELLIS (MD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:ELLIS
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 1:9460 N NAME UNO
Mailing Address - Street 2:#110
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-3537
Mailing Address - Country:US
Mailing Address - Phone:408-842-4466
Mailing Address - Fax:408-848-1355
Practice Address - Street 1:9460 N NAME UNO
Practice Address - Street 2:#110
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-3537
Practice Address - Country:US
Practice Address - Phone:408-842-4466
Practice Address - Fax:408-848-1355
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG454410207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA50042Medicare UPIN
CA00G454410Medicare ID - Type UnspecifiedMEDICARE NUMBER