1528065893 NPI number — RAMACHANDRA KOLLURU MD

Table of content: RAMACHANDRA KOLLURU MD (NPI 1528065893)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528065893 NPI number — RAMACHANDRA KOLLURU MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOLLURU
Provider First Name:
RAMACHANDRA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KOLLURU
Provider Other First Name:
RAMACHANDRA
Provider Other Middle Name:
RAO
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1528065893
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/20/2006
NPI Reactivation Date:
03/31/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 SANTA MARIA CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ODESSA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79765-8515
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
432-685-3333
Provider Business Mailing Address Fax Number:
432-570-5440

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
420E6TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ODESSA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79761-4537
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-685-3333
Provider Business Practice Location Address Fax Number:
432-570-5440
Provider Enumeration Date:
07/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  J0555 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 135590104 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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