Provider Demographics
NPI:1346250800
Name:KOLLURU, MANGARAJU (MD)
Entity Type:Individual
Prefix:DR
First Name:MANGARAJU
Middle Name:
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 1:1101 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:NC
Mailing Address - Zip Code:27576-3611
Mailing Address - Country:US
Mailing Address - Phone:919-965-6550
Mailing Address - Fax:919-975-1029
Practice Address - Street 1:1101 RIVER RD
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:NC
Practice Address - Zip Code:27576-3611
Practice Address - Country:US
Practice Address - Phone:919-965-9655
Practice Address - Fax:919-975-1029
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26290208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC82273Medicare UPIN