Provider Demographics
NPI:1114922713
Name:MUCKATIRA, BOPANNA (MD)
Entity Type:Individual
Prefix:
First Name:BOPANNA
Middle Name:
Last Name:MUCKATIRA
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 1:1904 PINE ST
Mailing Address - Street 2:STE 1 E
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79601-2449
Mailing Address - Country:US
Mailing Address - Phone:325-670-6900
Mailing Address - Fax:325-670-6905
Practice Address - Street 1:1904 PINE ST
Practice Address - Street 2:STE 1 E
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79601-2449
Practice Address - Country:US
Practice Address - Phone:325-670-6900
Practice Address - Fax:325-670-6905
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301065426207R00000X, 208M00000X
TXL4072207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0059NAOtherBCBSTX
TX1795775-01Medicaid
MIBM065426OtherBCBSM
TX1795775-01Medicaid
TX0059NAOtherBCBSTX
TX612069Medicare ID - Type Unspecified