Provider Demographics
NPI:1871535633
Name:KOLLA, SRINIVAS (MD)
Entity type:Individual
Prefix:
First Name:SRINIVAS
Middle Name:
Last Name:KOLLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 CLARKSON AVE
Mailing Address - Street 2:DEPT OF RADIOLOGY BOX 1198
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-2012
Mailing Address - Country:US
Mailing Address - Phone:718-270-1603
Mailing Address - Fax:
Practice Address - Street 1:450 CLARKSON AVE
Practice Address - Street 2:DEPT OF RADIOLOGY BOX 1198
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2056
Practice Address - Country:US
Practice Address - Phone:718-270-7378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA933642085R0202X
NY2380792085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02931946Medicaid
CA00A933640OtherMEDICAL
NY02321093OtherNY MEDICAID (GROUP)
CAWA93364BMedicare ID - Type Unspecified
NY02931946Medicaid
NY5K4761Medicare PIN
CAI65806Medicare UPIN