Provider Demographics
NPI:1326168139
Name:BOPPANA PRIMARY CARE CLINIC, PLLC
Entity Type:Organization
Organization Name:BOPPANA PRIMARY CARE CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SITA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOPPANA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-644-1100
Mailing Address - Street 1:PO BOX 830066
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75083-0066
Mailing Address - Country:US
Mailing Address - Phone:972-644-1100
Mailing Address - Fax:972-644-1107
Practice Address - Street 1:2460 N CENTRAL EXPY
Practice Address - Street 2:SUITE 101
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-2713
Practice Address - Country:US
Practice Address - Phone:972-644-1100
Practice Address - Fax:972-644-1107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX151198201Medicaid
TX151198201Medicaid