Provider Demographics
NPI:1164635173
Name:GREEN, DOUGLAS ALLEN (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:ALLEN
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD, PHD
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 2389
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92593-2389
Mailing Address - Country:US
Mailing Address - Phone:951-600-3811
Mailing Address - Fax:
Practice Address - Street 1:31700 TEMECULA PKWY
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-5896
Practice Address - Country:US
Practice Address - Phone:951-600-3811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1001132085R0202X, 208D00000X, 2085N0700X
GUMC-2072085R0202X
WI3992-3202085R0202X
WY16698C2085R0202X
IAMD-526802085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A1001130OtherBS OF CA
CA1164635173Medicaid
PA224510Medicare PIN
CAGV766WMedicare PIN
NYJ400052471Medicare PIN
CAGV766XMedicare PIN