Provider Demographics
NPI:1295928109
Name:KOLLI, GEETHA (MD)
Entity type:Individual
Prefix:
First Name:GEETHA
Middle Name:
Last Name:KOLLI
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 1:1441 N 12TH ST
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006
Mailing Address - Country:US
Mailing Address - Phone:602-521-5800
Mailing Address - Fax:
Practice Address - Street 1:1441 N 12TH ST
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2837
Practice Address - Country:US
Practice Address - Phone:602-521-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ37442207RI0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0008XAllopathic & Osteopathic PhysiciansInternal MedicineHepatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ37442OtherSTATE LICENSE
AZ37442OtherSTATE LICENSE
AZZ1437777Medicare UPIN
AZZ143780Medicare PIN
AZZ1483781Medicare PIN
AZZ143779Medicare UPIN