Provider Demographics
NPI:1881001006
Name:PATLOLLA, KEERTHI
Entity Type:Individual
Prefix:
First Name:KEERTHI
Middle Name:
Last Name:PATLOLLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KEERTHI
Other - Middle Name:
Other - Last Name:P
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:518-525-5634
Mailing Address - Fax:
Practice Address - Street 1:3935 BLACKSTONE AVE APT 9E
Practice Address - Street 2:RIVERDALE
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10471-3720
Practice Address - Country:US
Practice Address - Phone:718-584-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-21
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY291048207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program