Healthcare Provider Details

I. General information

NPI: 1275539017
Provider Name (Legal Business Name): BERNARD G. DE ASIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 01/06/2016
Certification Date:
Deactivation Date: 07/17/2007
Reactivation Date: 01/18/2008

III. Provider practice location address

117 SOUTH 11TH AVENUE
LAUREL MS
39440
US

IV. Provider business mailing address

P.O. BOX 4361
LAUREL MS
39441-4361
US

V. Phone/Fax

Practice location:
  • Phone: 601-425-3033
  • Fax: 601-422-0431
Mailing address:
  • Phone: 601-425-3033
  • Fax: 601-422-0431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number017249
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number17249
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: