Healthcare Provider Details

I. General information

NPI: 1487761854
Provider Name (Legal Business Name): BERNARD GEORGE BOKA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1014 D A BIGLANE DR
BROOKHAVEN MS
39601-2331
US

IV. Provider business mailing address

606 3RD ST
MCCOMB MS
39648-5102
US

V. Phone/Fax

Practice location:
  • Phone: 601-833-7973
  • Fax: 601-823-3514
Mailing address:
  • Phone: 601-341-0985
  • Fax: 601-823-3514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMS17139
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: