Healthcare Provider Details

I. General information

NPI: 1710362025
Provider Name (Legal Business Name): ESWARA KUMAR MUNDRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2015
Last Update Date: 01/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NORTH STATE STREET UNIVERSITY OF MISSISSIPPI MEDICAL CENTER RADIATION ONCO
JACKSON MS
39216-4505
US

IV. Provider business mailing address

2500 NORTH STATE STREET UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
JACKSON MS
39216-4505
US

V. Phone/Fax

Practice location:
  • Phone: 601-815-6886
  • Fax: 601-815-6876
Mailing address:
  • Phone: 601-815-6886
  • Fax: 601-815-6876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number947-L
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number947-L
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: