Provider Demographics
NPI:1942944467
Name:BOLLAVARAM, VIDYA KARTHINI (MD)
Entity Type:Individual
Prefix:
First Name:VIDYA
Middle Name:KARTHINI
Last Name:BOLLAVARAM
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 1:100 NORTH ACADEMY AVENUE
Mailing Address - Street 2:DANVILLE PA
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822
Mailing Address - Country:US
Mailing Address - Phone:570-271-6787
Mailing Address - Fax:
Practice Address - Street 1:100 NORTH ACADEMY AVENUE
Practice Address - Street 2:DANVILLE PA
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822
Practice Address - Country:US
Practice Address - Phone:570-271-6787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-21
Last Update Date:2023-01-25
Deactivation Date:2023-01-18
Deactivation Code:
Reactivation Date:2023-01-25
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program