Provider Demographics
NPI:1235230251
Name:KOLLOORI, BENJAMIN JOE (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:JOE
Last Name:KOLLOORI
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 1:1 EMERSON DR
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-1508
Mailing Address - Country:US
Mailing Address - Phone:718-273-2929
Mailing Address - Fax:718-816-6520
Practice Address - Street 1:1800 CLOVE ROAD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-1616
Practice Address - Country:US
Practice Address - Phone:718-273-2929
Practice Address - Fax:718-876-9179
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2012-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY133887207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A61989Medicare UPIN
30A801Medicare ID - Type Unspecified