Provider Demographics
NPI:1891947438
Name:MIKKILINENI, HARITHA (MD)
Entity Type:Individual
Prefix:DR
First Name:HARITHA
Middle Name:
Last Name:MIKKILINENI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-4150
Practice Address - Street 1:651 W MARION RD
Practice Address - Street 2:
Practice Address - City:MOUNT GILEAD
Practice Address - State:OH
Practice Address - Zip Code:43338-1027
Practice Address - Country:US
Practice Address - Phone:419-946-5015
Practice Address - Fax:937-619-4150
Is Sole Proprietor?:No
Enumeration Date:2008-10-15
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN5245207P00000X, 207R00000X, 207P00000X
NMMD2020-0327207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000719102OtherBCBS
KYP00955671OtherRR MEDICARE
KY7100066060Medicaid
KYP00955671OtherRR MEDICARE