Provider Demographics
NPI:1063709525
Name:GREEN, CIERRA CELESTE (MD)
Entity type:Individual
Prefix:DR
First Name:CIERRA
Middle Name:CELESTE
Last Name:GREEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CIERRA
Other - Middle Name:CELESTE
Other - Last Name:COLBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1729
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39403-1729
Mailing Address - Country:US
Mailing Address - Phone:601-545-8700
Mailing Address - Fax:601-450-2493
Practice Address - Street 1:66 OLD AIRPORT RD
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401
Practice Address - Country:US
Practice Address - Phone:601-544-7500
Practice Address - Fax:601-544-7524
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-06
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS23976207Q00000X
MI4301098722207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04774531Medicaid
MS12684749OtherCAQH