Healthcare Provider Details

I. General information

NPI: 1538131594
Provider Name (Legal Business Name): JONATHAN S. C. CAUDILL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 02/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 MEDICAL PARK DR
OXFORD MS
38655-5327
US

IV. Provider business mailing address

1203 MEDICAL PARK DR
OXFORD MS
38655-5327
US

V. Phone/Fax

Practice location:
  • Phone: 662-513-4399
  • Fax:
Mailing address:
  • Phone: 662-513-4399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number18119
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: