Provider Demographics
NPI:1164500682
Name:KOLLURU, GOPALA RAO (MD)
Entity Type:Individual
Prefix:
First Name:GOPALA
Middle Name:RAO
Last Name:KOLLURU
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 1:2287 MOWRY AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1622
Mailing Address - Country:US
Mailing Address - Phone:510-797-5057
Mailing Address - Fax:510-797-5058
Practice Address - Street 1:27206 CALAROGA AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94545-4300
Practice Address - Country:US
Practice Address - Phone:510-797-5057
Practice Address - Fax:510-797-5058
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38134207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A381340Medicaid
CAA3813410Medicaid
CA00A38134Medicare ID - Type Unspecified
CA00A381340Medicaid
CA00A381340Medicare PIN