Healthcare Provider Details

I. General information

NPI: 1114214038
Provider Name (Legal Business Name): GAGANDEEP SINGH GREWAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2011
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5001 HARDY ST
HATTIESBURG MS
39402-1308
US

IV. Provider business mailing address

5001 HARDY ST
HATTIESBURG MS
39402-1308
US

V. Phone/Fax

Practice location:
  • Phone: 601-296-2090
  • Fax: 601-296-2089
Mailing address:
  • Phone: 601-296-2090
  • Fax: 601-296-2089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number10170
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number23236
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: