Provider Demographics
NPI:1275539017
Name:DE ASIS, BERNARD G (MD)
Entity Type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:G
Last Name:DE ASIS
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:P.O. BOX 4361
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-4361
Mailing Address - Country:US
Mailing Address - Phone:601-425-3033
Mailing Address - Fax:601-422-0431
Practice Address - Street 1:117 SOUTH 11TH AVENUE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440
Practice Address - Country:US
Practice Address - Phone:601-425-3033
Practice Address - Fax:601-422-0431
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2016-01-06
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2008-01-18
Provider Licenses
StateLicense IDTaxonomies
MS017249173000000X
MS17249208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124990Medicaid
MS00124990Medicaid
MS370000339Medicare PIN
MSH45071Medicare UPIN