Provider Demographics
NPI:1750457230
Name:GREEN, MITHRA JIGME (DC)
Entity Type:Individual
Prefix:DR
First Name:MITHRA
Middle Name:JIGME
Last Name:GREEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5267 GREENWICH RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-6028
Mailing Address - Country:US
Mailing Address - Phone:757-313-6723
Mailing Address - Fax:757-313-4596
Practice Address - Street 1:5267 GREENWICH RD
Practice Address - Street 2:SUITE 201
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-6028
Practice Address - Country:US
Practice Address - Phone:757-313-6723
Practice Address - Fax:757-313-4596
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104555605111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA292354Medicare UPIN
GAP00326271Medicare ID - Type UnspecifiedPALMETTO GBA RAILROAD MC
VA2282482Medicare UPIN
VA3500001258Medicare PIN