Provider Demographics
NPI:1912928086
Name:GONDWE, JUSTICE AARON (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTICE
Middle Name:AARON
Last Name:GONDWE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:965 JK AVENT DRIVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901
Mailing Address - Country:US
Mailing Address - Phone:662-227-6450
Mailing Address - Fax:662-227-6452
Practice Address - Street 1:965 J K AVENT DR
Practice Address - Street 2:SUITE 106
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-5045
Practice Address - Country:US
Practice Address - Phone:662-227-6450
Practice Address - Fax:662-227-6452
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-22
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS20373207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0491951Medicaid
IA25140OtherBCBS
IA3116087Medicaid
IA420933383OtherEIN NUMBER
IAI17872Medicare ID - Type UnspecifiedMEDICARE PROV #
IAI17380Medicare ID - Type UnspecifiedMEDICARE GROUP #
IA0491951Medicaid