Provider Demographics
NPI:1003048687
Name:KOLLU, VIDYA SAGAR (MD)
Entity Type:Individual
Prefix:
First Name:VIDYA
Middle Name:SAGAR
Last Name:KOLLU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S BALLENGER HWY
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3638
Mailing Address - Country:US
Mailing Address - Phone:810-342-2000
Mailing Address - Fax:810-342-2000
Practice Address - Street 1:G3230 BEECHER RD
Practice Address - Street 2:SUITE 2
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3604
Practice Address - Country:US
Practice Address - Phone:810-342-5800
Practice Address - Fax:810-342-5810
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-17
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301093977207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine