Provider Demographics
NPI:1861846313
Name:GREEN, DAVID (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
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 1:764 LAKELAND DR FL 2
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4651
Mailing Address - Country:US
Mailing Address - Phone:601-984-6800
Mailing Address - Fax:601-984-6811
Practice Address - Street 1:102 LEXINGTON DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110
Practice Address - Country:US
Practice Address - Phone:601-973-1688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-21
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS26604207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine