Provider Demographics
NPI:1619030012
Name:GREEN, VIRGINIA LITTLE (MD)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:LITTLE
Last Name:GREEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VIRGINIA
Other - Middle Name:ALISON
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1700
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39215-1700
Mailing Address - Country:US
Mailing Address - Phone:601-987-3965
Mailing Address - Fax:601-987-5560
Practice Address - Street 1:350 W WOODROW WILSON AVE
Practice Address - Street 2:JACKSON MEDICAL MALL, SUITE 454
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-7681
Practice Address - Country:US
Practice Address - Phone:601-987-3965
Practice Address - Fax:601-987-4176
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10098208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS10098OtherMS BOARD OF MEDICAL LICENSURE
MS00122599Medicaid
MS00122599Medicaid