Provider Demographics
NPI:1801229505
Name:MUKKA, SANTOSH KUMAR (MD)
Entity Type:Individual
Prefix:
First Name:SANTOSH
Middle Name:KUMAR
Last Name:MUKKA
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 1:169 RIVERSIDE DR STE M12
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-4198
Mailing Address - Country:US
Mailing Address - Phone:607-798-6176
Mailing Address - Fax:
Practice Address - Street 1:169 RIVERSIDE DR STE M12
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-4198
Practice Address - Country:US
Practice Address - Phone:607-798-6176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-16
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY275919208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty