Basic Information
| Provider Information | |||||||||
| NPI: | 1124274063 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOKKA | ||||||||
| FirstName: | JAGAN MOHAN | ||||||||
| MiddleName: | REDDY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | I | ||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1005 HEALTH CENTER DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619384693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172386055 | ||||||||
| FaxNumber: | 2173484290 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 HEALTH CENTER DR | ||||||||
| Address2: | |||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619389261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172384325 | ||||||||
| FaxNumber: | 2173484290 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2008 | ||||||||
| LastUpdateDate: | 11/13/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 26478 | OK | N | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | 036-128216 | IL | N | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | 036-128216 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.