Healthcare Provider Details

I. General information

NPI: 1114922713
Provider Name (Legal Business Name): BOPANNA MUCKATIRA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 CYPRESS ST
ABILENE TX
79601-4117
US

IV. Provider business mailing address

1904 PINE ST STE 1 E
ABILENE TX
79601-2449
US

V. Phone/Fax

Practice location:
  • Phone: 325-670-6900
  • Fax: 325-670-6905
Mailing address:
  • Phone: 325-670-6900
  • Fax: 325-670-6905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number4301065426
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberL4072
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301065426
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: