Provider Demographics
NPI:1124274063
Name:BOKKA, JAGAN MOHAN REDDY I (MD)
Entity type:Individual
Prefix:
First Name:JAGAN MOHAN
Middle Name:REDDY
Last Name:BOKKA
Suffix:I
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 HEALTH CENTER DR STE 201
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4693
Mailing Address - Country:US
Mailing Address - Phone:217-238-6055
Mailing Address - Fax:217-348-4290
Practice Address - Street 1:1000 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-9261
Practice Address - Country:US
Practice Address - Phone:217-238-4325
Practice Address - Fax:217-348-4290
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-12
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK26478207Q00000X
IL036-128216208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist