Provider Demographics
NPI:1043255144
Name:KOLLURI, LAVANYA (MD)
Entity Type:Individual
Prefix:
First Name:LAVANYA
Middle Name:
Last Name:KOLLURI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3132 OLD JACKSONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-7401
Mailing Address - Country:US
Mailing Address - Phone:217-862-0062
Mailing Address - Fax:217-862-0064
Practice Address - Street 1:3132 OLD JACKSONVILLE RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-7400
Practice Address - Country:US
Practice Address - Phone:217-862-0062
Practice Address - Fax:217-862-0064
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036115509207R00000X
IN01064136A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN266180960OtherMEDICARE
IN300001136Medicaid