Provider Demographics
NPI:1306402870
Name:KOLLURI, POOJITHA (MD)
Entity Type:Individual
Prefix:MS
First Name:POOJITHA
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 1:2200 JEFFERSON AVENUE - MERCY FAMILY PHYSICIAN
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604
Mailing Address - Country:US
Mailing Address - Phone:419-251-1859
Mailing Address - Fax:419-251-4159
Practice Address - Street 1:200 S CEDAR ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62565-1838
Practice Address - Country:US
Practice Address - Phone:217-774-4400
Practice Address - Fax:217-774-6445
Is Sole Proprietor?:No
Enumeration Date:2019-05-10
Last Update Date:2022-05-13
Deactivation Date:2020-01-13
Deactivation Code:
Reactivation Date:2020-02-08
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036158456207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program