Provider Demographics
NPI:1841337656
Name:UNDESSER, CYNTHIA LUFKIN (MD)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:LUFKIN
Last Name:UNDESSER
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 1:402 WESLEY AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-1000
Mailing Address - Country:US
Mailing Address - Phone:601-360-0583
Mailing Address - Fax:601-360-0585
Practice Address - Street 1:402 WESLEY AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1000
Practice Address - Country:US
Practice Address - Phone:601-360-0583
Practice Address - Fax:601-360-0585
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS118912084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG5719OtherMEDICAL LICENSURE
MS00117736Medicaid