Provider Demographics
NPI:1780622480
Name:KOLLURI, GLENN IMMANUEL (ME87511)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:IMMANUEL
Last Name:KOLLURI
Suffix:
Gender:M
Credentials:ME87511
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-0417
Mailing Address - Country:US
Mailing Address - Phone:772-223-5665
Mailing Address - Fax:772-223-5646
Practice Address - Street 1:200 SE HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2346
Practice Address - Country:US
Practice Address - Phone:772-223-5618
Practice Address - Fax:772-223-5646
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME875112084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2674904-00Medicaid
FLH30683Medicare UPIN
FL78747Medicare PIN