Provider Demographics
NPI:1205156445
Name:BOLLAMPALLY, SOUMYA (DO)
Entity type:Individual
Prefix:
First Name:SOUMYA
Middle Name:
Last Name:BOLLAMPALLY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:856-355-0340
Mailing Address - Fax:856-355-0330
Practice Address - Street 1:200 BOWMAN DR STE E385 BACK
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-9638
Practice Address - Country:US
Practice Address - Phone:856-840-4534
Practice Address - Fax:856-762-2853
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-10
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAOS017602207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0497061Medicaid