Basic Information
| Provider Information | |||||||||
| NPI: | 1992943658 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUKKAVILLI | ||||||||
| FirstName: | VENKATA | ||||||||
| MiddleName: | MARTHANDA SASTRY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 845347 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752845347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146450624 | ||||||||
| FaxNumber: | 2146450078 | ||||||||
| Practice Location | |||||||||
| Address1: | 6363 FOREST PARK RD FL 7 | ||||||||
| Address2: | SUITE 749 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752355479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146458500 | ||||||||
| FaxNumber: | 2146483775 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2009 | ||||||||
| LastUpdateDate: | 03/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 24594 | WV | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 0101258929 | VA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084S0012X | Q3741 | TX | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Sleep Medicine | 390200000X | 233251 | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2084P0800X | Q3741 | TX | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.