Provider Demographics
NPI:1720366818
Name:KOLLI, GOUTHAM (MD)
Entity Type:Individual
Prefix:DR
First Name:GOUTHAM
Middle Name:
Last Name:KOLLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3008 W CINNAMON ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-6233
Mailing Address - Country:US
Mailing Address - Phone:605-496-8343
Mailing Address - Fax:
Practice Address - Street 1:1400 W 22ND ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1554
Practice Address - Country:US
Practice Address - Phone:605-357-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-24
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD9442207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1720366818Medicaid