Provider Demographics
NPI:1487608923
Name:MUKKA, MALLIKARJUNA R (MD)
Entity type:Individual
Prefix:
First Name:MALLIKARJUNA
Middle Name:R
Last Name:MUKKA
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6551 HARRIS PKWY STE 110
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-6105
Mailing Address - Country:US
Mailing Address - Phone:817-624-3500
Mailing Address - Fax:682-708-7225
Practice Address - Street 1:6551 HARRIS PKWY STE 110
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-6105
Practice Address - Country:US
Practice Address - Phone:817-624-3500
Practice Address - Fax:682-708-7225
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9822207RI0200X, 207R00000X
IL036140965208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX167966404Medicaid
I19258Medicare UPIN
TX167966405Medicaid
TXL9822OtherLICENSE
TX00Z531Medicare PIN