Provider Demographics
NPI:1487842696
Name:LEELA R BOLLA MD MEDICAL ASSOCIATES PA
Entity Type:Organization
Organization Name:LEELA R BOLLA MD MEDICAL ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEELA
Authorized Official - Middle Name:R
Authorized Official - Last Name:BOLLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-597-0544
Mailing Address - Street 1:1890 SW HEALTH PKWY
Mailing Address - Street 2:SUITE #100
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-0473
Mailing Address - Country:US
Mailing Address - Phone:239-597-0544
Mailing Address - Fax:239-597-8644
Practice Address - Street 1:1890 SW HEALTH PKWY
Practice Address - Street 2:SUITE #100
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-0473
Practice Address - Country:US
Practice Address - Phone:239-597-0544
Practice Address - Fax:239-597-8644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-12
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME79879207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD97973Medicare UPIN