Provider Demographics
NPI:1376753889
Name:CAUDELL, JIMMY (MD)
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:
Last Name:CAUDELL
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 1:131 PLANTATION DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-8553
Mailing Address - Country:US
Mailing Address - Phone:601-984-2550
Mailing Address - Fax:601-815-6876
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:DEPARTMENT OF RADIATION ONCOLOGY
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-2550
Practice Address - Fax:601-815-6876
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL268872085R0001X
MS205572085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
302I921397Medicare PIN