Provider Demographics
NPI:1104876028
Name:MUKKAMALA, SRINIVAS B (MD)
Entity type:Individual
Prefix:DR
First Name:SRINIVAS
Middle Name:B
Last Name:MUKKAMALA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1170 CHARTER DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3587
Mailing Address - Country:US
Mailing Address - Phone:810-244-8400
Mailing Address - Fax:810-244-8410
Practice Address - Street 1:1170 CHARTER DR
Practice Address - Street 2:SUITE F
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532
Practice Address - Country:US
Practice Address - Phone:810-244-8400
Practice Address - Fax:810-244-8410
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MISM075543207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4203511Medicaid
MI0M99540Medicare PIN
MIH13947Medicare UPIN