Healthcare Provider Details

I. General information

NPI: 1336158096
Provider Name (Legal Business Name): SRINIVASA C BOKKISAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 12/27/2022
Certification Date: 11/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7101 JAHNKE RD SUITE 611
RICHMOND VA
23225-4017
US

IV. Provider business mailing address

7101 JAHNKE RD SUITE 611
RICHMOND VA
23225-4017
US

V. Phone/Fax

Practice location:
  • Phone: 804-327-4046
  • Fax: 804-327-4047
Mailing address:
  • Phone: 804-327-4046
  • Fax: 804-327-4047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101239848
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0101239848
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number0101239848
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: