Healthcare Provider Details

I. General information

NPI: 1518911445
Provider Name (Legal Business Name): ACHYUTHA S PUJARI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 02/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 AVE B STE 200
ELLISVILLE MS
39437-2080
US

IV. Provider business mailing address

PO BOX 247
LAUREL MS
39441-0247
US

V. Phone/Fax

Practice location:
  • Phone: 601-477-3550
  • Fax: 601-477-2236
Mailing address:
  • Phone: 601-399-6167
  • Fax: 601-399-6281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number18395
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: