Basic Information
| Provider Information | |||||||||
| NPI: | 1568690865 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MULUKUTLA | ||||||||
| FirstName: | SURYA | ||||||||
| MiddleName: | NARAYAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2821 MICHAELANGELO DR STE 102B | ||||||||
| Address2: | |||||||||
| City: | EDINBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785391411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9563625650 | ||||||||
| FaxNumber: | 9563622599 | ||||||||
| Practice Location | |||||||||
| Address1: | 2821 MICHAELANGELO DR STE 102B | ||||||||
| Address2: | |||||||||
| City: | EDINBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785391411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9563625650 | ||||||||
| FaxNumber: | 9563622599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2009 | ||||||||
| LastUpdateDate: | 10/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | P4683 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 2080P0205X | P4683 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology |
ID Information
| ID | Type | State | Issuer | Description | 374872501 | 05 | TX | MEDICAID |