Basic Information
Provider Information
NPI: 1003138918
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MUKALLA
FirstName: SRILAKSHMI
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
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OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 635283
Address2:  
City: CINCINNATI
State: OH
PostalCode: 452635283
CountryCode: US
TelephoneNumber: 8596558980
FaxNumber: 8596558981
Practice Location
Address1: 1500 JAMES SIMPSON JR WAY
Address2: SUITE 201
City: COVINGTON
State: KY
PostalCode: 410110801
CountryCode: US
TelephoneNumber: 8596558980
FaxNumber: 8596558981
Other Information
ProviderEnumerationDate: 02/18/2010
LastUpdateDate: 09/12/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
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AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000X48690KYY Allopathic & Osteopathic PhysiciansInternal Medicine 

No ID Information.


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