Provider Demographics
NPI:1417397423
Name:MUNGARA, SAI SIVA JYOTHI KIRANMAI (MD)
Entity Type:Individual
Prefix:DR
First Name:SAI SIVA
Middle Name:JYOTHI KIRANMAI
Last Name:MUNGARA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-3499
Mailing Address - Country:US
Mailing Address - Phone:765-741-1515
Mailing Address - Fax:
Practice Address - Street 1:2401 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3499
Practice Address - Country:US
Practice Address - Phone:765-741-1515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-05
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01077084A174400000X, 390200000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201366300Medicaid
IN201366300Medicaid