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General NPI Number Information
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NPI Number | 1285064196
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Entity Type | Organization
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Legal Business Name | MITTAPALLI OBGYN PLLC
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Dates
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Enumeration Date | 11/14/2013
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Last Update Date | 07/14/2014
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Provider Practice Location Address
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Address Line | 845 E. B STREET
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City | SAN LUIS
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State | AZ
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Zip | 85349
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Country | US
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Telephone | 928-627-5678
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Fax | 928-627-5677
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Provider Business Mailing Address
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Address Line | PO BOX 8430
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City | SAN LUIS
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State | AZ
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Zip | 85349-6828
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Country | US
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Telephone | 928-627-5678
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Fax | 928-627-5677
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Authorized Official
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Title or Position | OWNER
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Name | RAJA MITTAPALLI
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Credential | MD
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Telephone | 330-206-9752
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | 36264
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License Number State | AZ
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