Provider Demographics
NPI:1831496165
Name:BODARYA, KETANKUMAR (MD)
Entity type:Individual
Prefix:
First Name:KETANKUMAR
Middle Name:
Last Name:BODARYA
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 1:2117 BROADWAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-3210
Mailing Address - Country:US
Mailing Address - Phone:601-288-8050
Mailing Address - Fax:601-288-8058
Practice Address - Street 1:2117 BROADWAY DRIVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-3210
Practice Address - Country:US
Practice Address - Phone:601-288-8050
Practice Address - Fax:601-288-8058
Is Sole Proprietor?:No
Enumeration Date:2011-02-23
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2021-005152084P0804X, 2084P0800X
MDD00811822084P0804X
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program