Healthcare Provider Details

I. General information

NPI: 1891006482
Provider Name (Legal Business Name): SRIKANTH MUKKERA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2010
Last Update Date: 06/04/2024
Certification Date: 06/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 W 5TH ST
ODESSA TX
79763-4206
US

IV. Provider business mailing address

701 W 5TH ST
ODESSA TX
79763-4206
US

V. Phone/Fax

Practice location:
  • Phone: 432-335-2222
  • Fax: 432-335-1815
Mailing address:
  • Phone: 432-335-2222
  • Fax: 432-335-1815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberTRN15469
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberS8215
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberS8215
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: