Provider Demographics
NPI:1538131594
Name:CAUDILL, JONATHAN S C (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:S C
Last Name:CAUDILL
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 1:1203 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5327
Mailing Address - Country:US
Mailing Address - Phone:662-513-4399
Mailing Address - Fax:
Practice Address - Street 1:1203 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5327
Practice Address - Country:US
Practice Address - Phone:662-513-4399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18119208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN590057300Medicaid
MN920000380Medicare PIN
I13623Medicare UPIN
MN590057300Medicaid