Provider Demographics
NPI:1780631002
Name:GREEN, MICHAEL STEPHEN (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:STEPHEN
Last Name:GREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5855 OLIVAS PARK DR
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-7672
Mailing Address - Country:US
Mailing Address - Phone:805-667-2801
Mailing Address - Fax:805-667-2865
Practice Address - Street 1:2361 E VINEYARD AVE
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-2102
Practice Address - Country:US
Practice Address - Phone:805-981-3770
Practice Address - Fax:805-981-3767
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG80363207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM08608FMedicaid
CA95-1683892OtherOTHER INSURANCE
CA050394OtherBLUE CROSS
CARHM08609FMedicaid
CARHM18553HMedicaid
CAZZT40394FMedicaid
CAZZT40394FMedicaid
CAWG80363HMedicare ID - Type UnspecifiedPPIN
CAWG80363GMedicare ID - Type UnspecifiedPPIN
CARHM18553HMedicaid
CARHM08609FMedicaid
CARHM08608FMedicaid
CA050394Medicare ID - Type UnspecifiedMEDICARE
CAWG80363CMedicare ID - Type UnspecifiedPPIN
CA95-1683892OtherOTHER INSURANCE
CA058609Medicare ID - Type UnspecifiedRH MEDICARE