Healthcare Provider Details

I. General information

NPI: 1831496165
Provider Name (Legal Business Name): KETANKUMAR BODARYA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2011
Last Update Date: 06/13/2025
Certification Date: 05/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2117 BROADWAY DRIVE
HATTIESBURG MS
39402-3210
US

IV. Provider business mailing address

2117 BROADWAY DRIVE
HATTIESBURG MS
39402-3210
US

V. Phone/Fax

Practice location:
  • Phone: 601-288-8050
  • Fax: 601-288-8058
Mailing address:
  • Phone: 601-288-8050
  • Fax: 601-288-8058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2021-00515
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number2021-00515
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberD0081182
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: