Basic Information
| Provider Information | |||||||||
| NPI: | 1770604803 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KURUBA | ||||||||
| FirstName: | RAJESH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 AVALON WAY | ||||||||
| Address2: | APT 1513 | ||||||||
| City: | BRANDON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390477533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487672363 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 E WOODROW WILSON AVE. | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392165199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013624471 | ||||||||
| FaxNumber: | 6013641357 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2007 | ||||||||
| LastUpdateDate: | 06/06/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 4301076797 | MI | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 20437 | MS | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 06872096 | 05 | MS | MEDICAID |