Provider Demographics
NPI:1417397423
Name:MUNGARA, SAI SIVA JYOTHI KIRANMAI (MD)
Entity type:Individual
Prefix:DR
First Name:SAI SIVA
Middle Name:JYOTHI KIRANMAI
Last Name:MUNGARA
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 1:701 W 5TH ST STE 3106
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79763-4206
Mailing Address - Country:US
Mailing Address - Phone:432-703-5340
Mailing Address - Fax:432-335-5297
Practice Address - Street 1:701 W 5TH ST STE 3106
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79763-4206
Practice Address - Country:US
Practice Address - Phone:432-703-5340
Practice Address - Fax:432-335-5297
Is Sole Proprietor?:No
Enumeration Date:2013-07-05
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01077084A207R00000X, 390200000X
TXR5295207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201366300Medicaid
IN201366300Medicaid