Provider Demographics
NPI:1598992794
Name:HUMPHREY, MARISSA (MD)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:
Other - Last Name:LYTTLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5931
Mailing Address - Fax:
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-15
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS23357207L00000X
NY253540207R00000X
ORMD214825207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06457521Medicaid
MSP01454807OtherRAILROAD MEDICARE PTAN
MS371995YS8TMedicare PIN