Provider Demographics
NPI:1124584800
Name:PEREKATTU KURUVILLA, TEESSA (MD)
Entity Type:Individual
Prefix:
First Name:TEESSA
Middle Name:
Last Name:PEREKATTU KURUVILLA
Suffix:
Gender:F
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:UNIVERSITY OF MS MEDICAL CENTER
Mailing Address - Street 2:2500 N STATE ST DEPARTMENT OF RADIATION ONCOLOGY
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4505
Mailing Address - Country:US
Mailing Address - Phone:601-815-6886
Mailing Address - Fax:601-815-1846
Practice Address - Street 1:DEPARTMENT OF RADIATION ONCOLOGY
Practice Address - Street 2:350 WOODROW WILSON DR
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4505
Practice Address - Country:US
Practice Address - Phone:601-815-6886
Practice Address - Fax:601-815-1846
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-37262085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MST-3726OtherMS STATE BOARD OF MEDICAL LICENSURE