Provider Demographics
NPI:1922250059
Name:BOPANNA MUCKATIRA MD, PA
Entity Type:Organization
Organization Name:BOPANNA MUCKATIRA MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BOPANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MUCKATIRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:325-670-6900
Mailing Address - Street 1:1904 PINE ST
Mailing Address - Street 2:1 E
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79601-2449
Mailing Address - Country:US
Mailing Address - Phone:325-670-6900
Mailing Address - Fax:325-670-6905
Practice Address - Street 1:1904 PINE ST
Practice Address - Street 2:1 E
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79601-2449
Practice Address - Country:US
Practice Address - Phone:325-670-6900
Practice Address - Fax:325-670-6905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0059 NAOtherBCBS
TX1795775-01Medicaid
TX612069Medicare PIN