Provider Demographics
NPI:1508983644
Name:MUKKAVILLI, KAMAKSHI K (MD)
Entity Type:Individual
Prefix:
First Name:KAMAKSHI
Middle Name:K
Last Name:MUKKAVILLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KAY
Other - Middle Name:
Other - Last Name:MUKKAVILLI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:7227 E BASELINE RD STE 126
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-5006
Mailing Address - Country:US
Mailing Address - Phone:480-868-9650
Mailing Address - Fax:480-834-3606
Practice Address - Street 1:7227 E BASELINE RD STE 126
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-5006
Practice Address - Country:US
Practice Address - Phone:480-868-9650
Practice Address - Fax:480-834-3606
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME134144207R00000X, 207RG0300X
AZ29911207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL025032900Medicaid
AZZ116955Medicare PIN
AZ685935Medicaid