Provider Demographics
NPI:1629854690
Name:MHYA CLINIC PLLC
Entity Type:Organization
Organization Name:MHYA CLINIC PLLC
Other - Org Name:MHYA CLINIC PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HARITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIKKILINENI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-583-0575
Mailing Address - Street 1:420 N KIMBALL AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6995
Mailing Address - Country:US
Mailing Address - Phone:817-583-0575
Mailing Address - Fax:
Practice Address - Street 1:420 N KIMBALL AVE STE 140
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6995
Practice Address - Country:US
Practice Address - Phone:817-583-0575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-06
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty