Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204C00000X | Sports Medicine Doctor | PT9145 | CA |
NPI | 1568487049 |
---|---|
Provider Name | David Green |
First Address | Mission Viejo, CA 92691-5815 |
Second Address | Mission Viejo, CA 92691-5815 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/07/2006 |
Last Update Date | 08/07/2007 |