Provider Demographics
NPI:1386680874
Name:BOLLA, BHUPINDER S (MD)
Entity Type:Individual
Prefix:
First Name:BHUPINDER
Middle Name:S
Last Name:BOLLA
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:PO BOX 6684
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-6684
Mailing Address - Country:US
Mailing Address - Phone:315-782-7246
Mailing Address - Fax:315-782-7247
Practice Address - Street 1:26561 STATE ROUTE 3 STE A
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-1749
Practice Address - Country:US
Practice Address - Phone:157-827-2463
Practice Address - Fax:315-782-7247
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252773-1208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02601054Medicaid
RA2996Medicare PIN
NYH66577Medicare UPIN