Provider Demographics
NPI:1053306522
Name:BOCKHORST, JAMES LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:LEE
Last Name:BOCKHORST
Suffix:
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 1:176 GORGET DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MO
Mailing Address - Zip Code:63379-2538
Mailing Address - Country:US
Mailing Address - Phone:636-528-2321
Mailing Address - Fax:
Practice Address - Street 1:1177 E CHERRY ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-1520
Practice Address - Country:US
Practice Address - Phone:636-528-1919
Practice Address - Fax:636-528-1916
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO221366207R00000X
MO077577208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208774109Medicaid
MO500600026Medicare PIN
MO208774109Medicaid