Healthcare Provider Details

I. General information

NPI: 1437123825
Provider Name (Legal Business Name): CARLA G MONICO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 01/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 N STATE ST DIVISION OF NEPHROLOGY
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5970
  • Fax: 601-984-5902
Mailing address:
  • Phone: 601-984-5970
  • Fax: 601-984-5902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number38268
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: