Provider Demographics
NPI:1598721326
Name:GOLLA, BHASKAR N/A (MD)
Entity Type:Individual
Prefix:DR
First Name:BHASKAR
Middle Name:N/A
Last Name:GOLLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:500 MEMORIAL CIR
Mailing Address - Street 2:SUITE B
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5071
Mailing Address - Country:US
Mailing Address - Phone:386-673-8040
Mailing Address - Fax:386-267-0693
Practice Address - Street 1:500 MEMORIAL CIR
Practice Address - Street 2:SUITE B
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5054
Practice Address - Country:US
Practice Address - Phone:386-673-8040
Practice Address - Fax:386-267-0693
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME00869702085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology