Basic Information
| Provider Information | |||||||||
| NPI: | 1851330674 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | HOWARD | ||||||||
| MiddleName: | I. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2200 | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923730722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097933311 | ||||||||
| FaxNumber: | 9097964158 | ||||||||
| Practice Location | |||||||||
| Address1: | 6109 W RAMSEY ST | ||||||||
| Address2: | |||||||||
| City: | BANNING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922203051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9518450313 | ||||||||
| FaxNumber: | 9097964158 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | G41712 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G417120 | 05 | CA | MEDICAID |