Provider Demographics
NPI:1043535586
Name:GOLLA, MICHELLE CLARICE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:CLARICE
Last Name:GOLLA
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 1:6503 E BROAD ST STE 100
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-1693
Mailing Address - Country:US
Mailing Address - Phone:614-434-5437
Mailing Address - Fax:
Practice Address - Street 1:6503 E BROAD ST STE 100
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-1693
Practice Address - Country:US
Practice Address - Phone:614-434-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-27
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35099603208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0087407Medicaid