Healthcare Provider Details

I. General information

NPI: 1912928086
Provider Name (Legal Business Name): JUSTICE AARON GONDWE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 04/21/2025
Certification Date: 04/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

965 J K AVENT DR SUITE 106
GRENADA MS
38901-5045
US

IV. Provider business mailing address

965 JK AVENT DRIVE SUITE 106
GRENADA MS
38901
US

V. Phone/Fax

Practice location:
  • Phone: 662-227-6450
  • Fax: 662-227-6452
Mailing address:
  • Phone: 662-227-6450
  • Fax: 662-227-6452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number20373
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: