Provider Demographics
NPI:1215116660
Name:MALLIKARJUNA MUKKA MD PA
Entity type:Organization
Organization Name:MALLIKARJUNA MUKKA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MALLIKARJUNA
Authorized Official - Middle Name:R
Authorized Official - Last Name:MUKKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-624-3500
Mailing Address - Street 1:6551 HARRIS PKWY STE 110
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-6105
Mailing Address - Country:US
Mailing Address - Phone:817-624-3500
Mailing Address - Fax:817-527-5305
Practice Address - Street 1:6551 HARRIS PKWY STE 110
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-6105
Practice Address - Country:US
Practice Address - Phone:817-624-3500
Practice Address - Fax:682-708-7225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-01
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RI0200X
TXL9822305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX208321401Medicaid