MEDICARE: BOPPANA PRIMARY CARE CLINIC, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326168139
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOPPANA PRIMARY CARE CLINIC, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 830066
Second Line	:
City	:	RICHARDSON
State	:	TX
Zip	:	75083-0066
Country	:	US
Telephone Number	:	972-644-1100
Fax Number	:	972-644-1107

Provider Business Practice Location Address
First Line	:	2460 N CENTRAL EXPY
Second Line	:	SUITE 101
City	:	RICHARDSON
State	:	TX
Zip	:	75080-2713
Country	:	US
Telephone Number	:	972-644-1100
Fax Number	:	972-644-1107

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SITA M BOPPANA
Credential	:	M.D.
Telephone Number	:	972-644-1100

Provider Enumeration Date	:	03/29/2007
Last Update Date	:	11/05/2018

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