Provider Demographics
NPI:1275898280
Name:KOLLURI, SUVARNA (MD)
Entity Type:Individual
Prefix:
First Name:SUVARNA
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 1:809 GLEN ABBEY DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-1314
Mailing Address - Country:US
Mailing Address - Phone:908-249-3487
Mailing Address - Fax:
Practice Address - Street 1:9509 N BEACH ST STE 102
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-6399
Practice Address - Country:US
Practice Address - Phone:817-617-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-06
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ0088208000000X
AZ46281208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics