Provider Demographics
NPI:1477586428
Name:KOLLURI, PAVAN (MD)
Entity Type:Individual
Prefix:
First Name:PAVAN
Middle Name:
Last Name:KOLLURI
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 1:204 TALCOTT RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-2394
Mailing Address - Country:US
Mailing Address - Phone:860-648-4032
Mailing Address - Fax:260-407-8004
Practice Address - Street 1:204 TALCOTT RIDGE RD
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-2394
Practice Address - Country:US
Practice Address - Phone:860-648-4032
Practice Address - Fax:260-407-8004
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36831207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64036676Medicaid
KY930109200OtherRAILROAD
H47139Medicare UPIN
KY930109200OtherRAILROAD