Provider Demographics
NPI:1114955101
Name:SAWARDECKER, SANDIP (MD)
Entity Type:Individual
Prefix:DR
First Name:SANDIP
Middle Name:
Last Name:SAWARDECKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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:601-984-5373
Mailing Address - Fax:601-984-5476
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:601-984-5373
Practice Address - Fax:601-984-5476
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13332207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS160058383OtherRR MEDICARE NUMBER
MS09014712Medicaid
MS09014712Medicaid
MSE10422Medicare UPIN
MS160000473Medicare ID - Type UnspecifiedMCRE INDV PROV NUMBER
MS09014712Medicaid
MSC00319Medicare ID - Type UnspecifiedMCRE GROUP PROV NUMBER
MS00123192Medicaid
MS08103071OtherUP MEDICAID GROUP PROV #