Basic Information
| Provider Information | |||||||||
| NPI: | 1457491383 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JAGWANI | ||||||||
| FirstName: | SUNDER | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1410 | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 389351410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6624592613 | ||||||||
| FaxNumber: | 6624591159 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 RIVER RD | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 389304030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6624592613 | ||||||||
| FaxNumber: | 6624591159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | 10551 | MS | Y | Allopathic & Osteopathic Physicians | Radiology | Body Imaging |
ID Information
| ID | Type | State | Issuer | Description | 00123335 | 05 | MS | MEDICAID | 09015650 | 05 | MS | MEDICAID |