Provider Demographics
NPI:1871523787
Name:KOLLIPARA, ANURADHA (MD)
Entity type:Individual
Prefix:DR
First Name:ANURADHA
Middle Name:
Last Name:KOLLIPARA
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 1:7972 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4140
Mailing Address - Country:US
Mailing Address - Phone:260-436-0281
Mailing Address - Fax:260-459-2779
Practice Address - Street 1:7972 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-436-0281
Practice Address - Fax:260-459-2779
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01046950207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000093479OtherBLUE CROSS BLUE SHIELD
110212244OtherRAILROAD MEDICARE
IN200197730Medicaid
IN139950Medicare PIN
000000093479OtherBLUE CROSS BLUE SHIELD
110212244OtherRAILROAD MEDICARE