Provider Demographics
NPI:1255567798
Name:LITTLE, WILBUR T
Entity type:Individual
Prefix:MR
First Name:WILBUR
Middle Name:T
Last Name:LITTLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 PALISADE POINT DR
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-4528
Mailing Address - Country:US
Mailing Address - Phone:404-386-7270
Mailing Address - Fax:
Practice Address - Street 1:141 PALISADE POINT DR.
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294
Practice Address - Country:US
Practice Address - Phone:404-386-7270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-10
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA870757549Medicaid