Provider Demographics
NPI:1316098833
Name:MUNDINGER, GERHARD H (MD)
Entity type:Individual
Prefix:DR
First Name:GERHARD
Middle Name:H
Last Name:MUNDINGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 CHADWICK DR
Mailing Address - Street 2:SUITE 256
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-3463
Mailing Address - Country:US
Mailing Address - Phone:601-376-1934
Mailing Address - Fax:601-376-2005
Practice Address - Street 1:1860 CHADWICK DR
Practice Address - Street 2:SUITE 256
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-3463
Practice Address - Country:US
Practice Address - Phone:601-376-1934
Practice Address - Fax:601-376-2005
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11122208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00116202Medicaid
MS00116202Medicaid
MSB30613Medicare UPIN