Provider Demographics
NPI:1952336752
Name:GREEN, LYDIA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:MARIE
Last Name:GREEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2851 W 120TH ST STE E-134
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-3395
Mailing Address - Country:US
Mailing Address - Phone:323-691-1772
Mailing Address - Fax:
Practice Address - Street 1:6033 W CENTURY BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-6440
Practice Address - Country:US
Practice Address - Phone:323-691-1772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA068297207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACE352ZMedicare UPIN
CACE352WMedicare UPIN
CACE352UMedicare UPIN
CACE787GMedicare PIN
CACE787BCMedicare PIN
CACE787AMedicare PIN
CACE352TMedicare UPIN
CACE787FMedicare PIN
CACE787EMedicare PIN
CACE787DMedicare PIN
CAZZZ07334ZMedicare PIN
CACE352YMedicare UPIN
CACE352VMedicare UPIN
CACE352XMedicare UPIN
CACE787CMedicare PIN
CACE787BMedicare PIN
CACE352SMedicare UPIN