MEDICARE: VENKATA MARTHANDA SASTRY MUKKAVILLI MD

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	207QS1201X	Sleep Medicine (Family Medicine) Physician	Q3741	TX
2	2084P0800X	Psychiatry Physician	24594	WV
3	2084P0800X	Psychiatry Physician	0101258929	VA
4	2084S0012X	Sleep Medicine (Psychiatry & Neurology) Physician	Q3741	TX
5	390200000X	Student in an Organized Health Care Education/Training Program	233251
6	2084P0800X	Psychiatry Physician	Q3741	TX

General Provider Information

NPI Number	:	1992943658
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VENKATA MARTHANDA SASTRY MUKKAVILLI MD

Provider Business Mailing Address
First Line	:	PO BOX 845347
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-5347
Country	:	US
Telephone Number	:	214-645-0624
Fax Number	:	214-645-0078

Provider Business Practice Location Address
First Line	:	6363 FOREST PARK RD FL 7
Second Line	:	SUITE 749
City	:	DALLAS
State	:	TX
Zip	:	75235-5479
Country	:	US
Telephone Number	:	214-645-8500
Fax Number	:	214-648-3775

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/03/2009
Last Update Date	:	12/30/2022

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