Provider Demographics
NPI:1992943658
Name:MUKKAVILLI, VENKATA MARTHANDA SASTRY (MD)
Entity type:Individual
Prefix:
First Name:VENKATA
Middle Name:MARTHANDA SASTRY
Last Name:MUKKAVILLI
Suffix:
Gender:M
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:PO BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:214-645-0624
Mailing Address - Fax:214-645-0078
Practice Address - Street 1:6363 FOREST PARK RD FL 7
Practice Address - Street 2:SUITE 749
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-5479
Practice Address - Country:US
Practice Address - Phone:214-645-8500
Practice Address - Fax:214-648-3775
Is Sole Proprietor?:No
Enumeration Date:2009-02-03
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ3741207QS1201X, 2084S0012X, 2084P0800X
WV245942084P0800X
VA01012589292084P0800X
233251390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207QS1201XAllopathic & Osteopathic PhysiciansFamily MedicineSleep Medicine
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program