Provider Demographics
NPI:1568845220
Name:GOLLAKOTA, SANJIV (DO)
Entity Type:Individual
Prefix:
First Name:SANJIV
Middle Name:
Last Name:GOLLAKOTA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST STE 500
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:317-621-9312
Mailing Address - Fax:317-621-6920
Practice Address - Street 1:3000 S STATE ROAD 135 STE 310
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143
Practice Address - Country:US
Practice Address - Phone:317-497-2400
Practice Address - Fax:317-497-2515
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT016591207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine