Provider Demographics
NPI:1013017292
Name:KOLLI, VIJAY K (MD)
Entity Type:Individual
Prefix:
First Name:VIJAY
Middle Name:K
Last Name:KOLLI
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 1:1104E STATE HIGHWAY 152
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-5116
Mailing Address - Country:US
Mailing Address - Phone:855-541-2862
Mailing Address - Fax:405-716-4808
Practice Address - Street 1:1104E STATE HIGHWAY 152
Practice Address - Street 2:
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064-5116
Practice Address - Country:US
Practice Address - Phone:405-376-9544
Practice Address - Fax:405-376-1831
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK28955207RI0200X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA27412OtherWELLMARK BLUE SHIELD
IA0726323Medicaid
IAI69188Medicare UPIN
IAI19427Medicare ID - Type Unspecified