Provider Demographics
NPI:1205173614
Name:GOTTIMUKKALA, SRI B (MD)
Entity type:Individual
Prefix:
First Name:SRI
Middle Name:B
Last Name:GOTTIMUKKALA
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 1:1400 N COIT RD STE 2502
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75071-6664
Mailing Address - Country:US
Mailing Address - Phone:469-430-0911
Mailing Address - Fax:281-747-1452
Practice Address - Street 1:1400 N COIT RD STE 2502
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75071-6664
Practice Address - Country:US
Practice Address - Phone:972-295-9000
Practice Address - Fax:281-747-1452
Is Sole Proprietor?:No
Enumeration Date:2013-01-07
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ3877207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX351833402Medicaid
TX351833401Medicaid
TX8FX392OtherBLUE CROSS BLUE SHIELD
TX8FK130OtherBLUE CROSS BLUE SHIELD
TX351833402Medicaid
TX351833401Medicaid