Provider Demographics
NPI:1780676197
Name:KOLLI, V R (MD)
Entity Type:Individual
Prefix:DR
First Name:V
Middle Name:R
Last Name:KOLLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:VENKAT
Other - Middle Name:R
Other - Last Name:KOLLI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1250 E. CLIFF DR.
Mailing Address - Street 2:SUITE 4A
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-4846
Mailing Address - Country:US
Mailing Address - Phone:915-541-7000
Mailing Address - Fax:915-541-7002
Practice Address - Street 1:SUITE 4A 1250 E. CLIFF DR.
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902
Practice Address - Country:US
Practice Address - Phone:915-541-7000
Practice Address - Fax:915-541-7002
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ5805207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX119036501Medicaid
TXF44134Medicare UPIN
TX119036501Medicaid