Provider Demographics
NPI:1629035340
Name:MOOLAMALLA, KAVITHA
Entity Type:Individual
Prefix:
First Name:KAVITHA
Middle Name:
Last Name:MOOLAMALLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8080 STATE HIGHWAY 121
Mailing Address - Street 2:STE 240
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75070-2902
Mailing Address - Country:US
Mailing Address - Phone:972-542-2683
Mailing Address - Fax:972-548-7657
Practice Address - Street 1:8080 STATE HIGHWAY 121 STE 210
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75070-2902
Practice Address - Country:US
Practice Address - Phone:972-268-9383
Practice Address - Fax:972-870-4925
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1573207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0065EQOtherBLUE CROSS BLUE SHIELD
G62226Medicare UPIN
TX00433MMedicare PIN