Provider Demographics
NPI:1508487760
Name:BASCOME, MAKALA MARIE (DO)
Entity Type:Individual
Prefix:
First Name:MAKALA
Middle Name:MARIE
Last Name:BASCOME
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 FULLER RD BLDG 367
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39309-5106
Mailing Address - Country:US
Mailing Address - Phone:601-679-3968
Mailing Address - Fax:
Practice Address - Street 1:1801 FULLER RD # 367
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39309-0004
Practice Address - Country:US
Practice Address - Phone:601-679-3968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-29
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102206849208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice