Provider Demographics
NPI:1033318985
Name:SUNDER JAGWANI MD PA
Entity Type:Organization
Organization Name:SUNDER JAGWANI MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:SUNDER
Authorized Official - Middle Name:
Authorized Official - Last Name:JAGWANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-636-0097
Mailing Address - Street 1:1401 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-4030
Mailing Address - Country:US
Mailing Address - Phone:601-636-0097
Mailing Address - Fax:601-629-9969
Practice Address - Street 1:1401 RIVER RD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-4030
Practice Address - Country:US
Practice Address - Phone:601-636-0097
Practice Address - Fax:601-629-9969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-12
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS105512085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08707229Medicaid
MS08707229Medicaid