Provider Demographics
NPI:1982631727
Name:MUKKAMALA, SRIDEVI (MD)
Entity Type:Individual
Prefix:
First Name:SRIDEVI
Middle Name:
Last Name:MUKKAMALA
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 1:909 N WASHINGTON AVE
Mailing Address - Street 2:SUITE 115
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1520
Mailing Address - Country:US
Mailing Address - Phone:214-820-9305
Mailing Address - Fax:214-820-9369
Practice Address - Street 1:909 N WASHINGTON AVE
Practice Address - Street 2:SUITE 115
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1520
Practice Address - Country:US
Practice Address - Phone:214-820-9305
Practice Address - Fax:214-820-9369
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002389208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8CL085OtherBCBSTX
NY02673949Medicaid
TX217154801Medicaid
L023895WCPMROtherWORKERS COMP
I41192Medicare UPIN
TXTXB112115Medicare PIN
TXP00941893Medicare PIN
NYRA7975-GRP:70008AMedicare PIN
TX8CL085OtherBCBSTX