Provider Demographics
NPI:1649240615
Name:KOLLI, PAVANI (MD)
Entity Type:Individual
Prefix:
First Name:PAVANI
Middle Name:
Last Name:KOLLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24604 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1742
Mailing Address - Country:US
Mailing Address - Phone:313-908-9374
Mailing Address - Fax:313-562-8511
Practice Address - Street 1:24604 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1742
Practice Address - Country:US
Practice Address - Phone:313-908-9374
Practice Address - Fax:313-562-8511
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301074415207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4600306Medicaid
H79115Medicare UPIN