Provider Demographics
NPI:1013964782
Name:MUNGAN, NILS K (MD)
Entity Type:Individual
Prefix:DR
First Name:NILS
Middle Name:K
Last Name:MUNGAN
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:601-984-5024
Mailing Address - Fax:601-815-3773
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:601-984-5024
Practice Address - Fax:601-815-3773
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16417207WX0110X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0110XAllopathic & Osteopathic PhysiciansOphthalmologyPediatric Ophthalmology and Strabismus Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS180041190OtherRAILROAD MEDICARE
MSP00462293OtherRAILROAD MEDICARE
MS00121091Medicaid
AL194374Medicaid
MSP01236791OtherRAILROAD MEDICARE
MSP00462293OtherRAILROAD MEDICARE
MS512I180006Medicare PIN
MSG15356Medicare UPIN