Provider Demographics
NPI:1710346671
Name:KOLLU, VIDYA
Entity Type:Individual
Prefix:
First Name:VIDYA
Middle Name:
Last Name:KOLLU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1345 W CENTRAL PARK AVE
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52804-1844
Mailing Address - Country:US
Mailing Address - Phone:563-421-1900
Mailing Address - Fax:563-421-1809
Practice Address - Street 1:1345 W CENTRAL PARK AVE
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52804-1844
Practice Address - Country:US
Practice Address - Phone:563-421-1900
Practice Address - Fax:563-421-1809
Is Sole Proprietor?:No
Enumeration Date:2016-02-19
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-43419207R00000X
WI69007207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1710346671Medicaid