Provider Demographics
NPI:1366426421
Name:GREEN, GARTH A
Entity type:Individual
Prefix:
First Name:GARTH
Middle Name:A
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 512185
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051
Mailing Address - Country:US
Mailing Address - Phone:626-775-3514
Mailing Address - Fax:
Practice Address - Street 1:5215 TORRANCE BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503
Practice Address - Country:US
Practice Address - Phone:310-750-1715
Practice Address - Fax:310-792-6551
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA515472085R0001X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A515470Medicaid
CAWA51547GMedicare PIN
CA920005402Medicare PIN
CA00A515470Medicaid
CAWA51547IMedicare PIN
CAWA51547CMedicare PIN
CAWA51547AMedicare PIN
CAG30494Medicare UPIN
CAWA51547EMedicare PIN