Provider Demographics
NPI:1093888216
Name:SRINIVAS B. MUKKAMALA. M.D., P.L.C.
Entity Type:Organization
Organization Name:SRINIVAS B. MUKKAMALA. M.D., P.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SRINIVAS
Authorized Official - Middle Name:B
Authorized Official - Last Name:MUKKAMALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-244-8400
Mailing Address - Street 1:1170 CHARTER DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3587
Mailing Address - Country:US
Mailing Address - Phone:810-244-8400
Mailing Address - Fax:
Practice Address - Street 1:1170 CHARTER DR
Practice Address - Street 2:SUITE F
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532
Practice Address - Country:US
Practice Address - Phone:810-244-8400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301075543174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4203511Medicaid
MIH13947Medicare UPIN
MI0P47180Medicare PIN