Healthcare Provider Details

I. General information

NPI: 1518961036
Provider Name (Legal Business Name): THOMAS JOB MUKKADA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 E ALTA VISTA AVE
OTTUMWA IA
52501-1413
US

IV. Provider business mailing address

312 E ALTA VISTA AVE
OTTUMWA IA
52501-1413
US

V. Phone/Fax

Practice location:
  • Phone: 641-682-4115
  • Fax: 641-682-0005
Mailing address:
  • Phone: 641-682-4115
  • Fax: 641-682-0005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number28127
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: