Provider Demographics
NPI:1639353139
Name:BOLLINENI, MAMATHA (MD)
Entity Type:Individual
Prefix:DR
First Name:MAMATHA
Middle Name:
Last Name:BOLLINENI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MAMATHA
Other - Middle Name:
Other - Last Name:BOLLINENI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:11521 N FM 620
Mailing Address - Street 2:SUITE C-800
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78726-1139
Mailing Address - Country:US
Mailing Address - Phone:512-219-0670
Mailing Address - Fax:512-219-0733
Practice Address - Street 1:11521 N FM 620
Practice Address - Street 2:SUITE C-800
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78726-1139
Practice Address - Country:US
Practice Address - Phone:512-219-0670
Practice Address - Fax:512-219-0733
Is Sole Proprietor?:No
Enumeration Date:2007-12-20
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA246435207R00000X
TXQ1951207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPENDINGMedicare PIN