Provider Demographics
NPI:1881702504
Name:GREEN, STUART ALAN (MD)
Entity type:Individual
Prefix:DR
First Name:STUART
Middle Name:ALAN
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 1:1040 ELM AVENUE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACG
Mailing Address - State:CA
Mailing Address - Zip Code:90813-3265
Mailing Address - Country:US
Mailing Address - Phone:562-430-3561
Mailing Address - Fax:562-431-8882
Practice Address - Street 1:3771 KATELLA AVE
Practice Address - Street 2:SUITE 310
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3108
Practice Address - Country:US
Practice Address - Phone:562-430-3561
Practice Address - Fax:562-431-8882
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG22945174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG22945OtherLICENSE
CA00G229450Medicaid
CAWG22945EMedicare PIN