1710362025 NPI number — DR. ESWARA KUMAR MUNDRA MD

Table of content: DR. ESWARA KUMAR MUNDRA MD (NPI 1710362025)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710362025 NPI number — DR. ESWARA KUMAR MUNDRA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUNDRA
Provider First Name:
ESWARA
Provider Middle Name:
KUMAR
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710362025
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2500 NORTH STATE STREET
Provider Second Line Business Mailing Address:
UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39216-4505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-815-6886
Provider Business Mailing Address Fax Number:
601-815-6876

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2500 NORTH STATE STREET
Provider Second Line Business Practice Location Address:
UNIVERSITY OF MISSISSIPPI MEDICAL CENTER RADIATION ONCO
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39216-4505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-815-6886
Provider Business Practice Location Address Fax Number:
601-815-6876
Provider Enumeration Date:
07/28/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  947-L , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0001X , with the licence number: 947-L , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 07083393 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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