Provider Demographics
NPI:1598970089
Name:MUKKAMALA, PRASADARAO B (MD)
Entity Type:Individual
Prefix:DR
First Name:PRASADARAO
Middle Name:B
Last Name:MUKKAMALA
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:UNION SQUARE, ONE MONONGALIA STREET
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302
Mailing Address - Country:US
Mailing Address - Phone:304-344-5153
Mailing Address - Fax:304-344-5184
Practice Address - Street 1:UNION SQUARE, ONE MONONGALIA STREET
Practice Address - Street 2:SUITE 3
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302
Practice Address - Country:US
Practice Address - Phone:304-344-5153
Practice Address - Fax:304-344-5184
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV118802081H0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081H0002XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0113321000Medicaid
WV1022886OtherWORKERS' COMPENSATION
WV0496812Medicare ID - Type Unspecified
WV1022886OtherWORKERS' COMPENSATION