Provider Demographics
NPI:1861507915
Name:BOLLA, SUDHA (MD)
Entity Type:Individual
Prefix:
First Name:SUDHA
Middle Name:
Last Name:BOLLA
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 1:41 MONTVALE AVE
Mailing Address - Street 2:
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-2445
Mailing Address - Country:US
Mailing Address - Phone:781-224-5810
Mailing Address - Fax:781-224-5817
Practice Address - Street 1:41 MONTVALE AVE
Practice Address - Street 2:
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-2445
Practice Address - Country:US
Practice Address - Phone:781-224-5810
Practice Address - Fax:781-224-5817
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA228731207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine