Provider Demographics
NPI:1871582288
Name:KOLLI, SUSMITHA P (MD)
Entity type:Individual
Prefix:
First Name:SUSMITHA
Middle Name:P
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 1:1500 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-3478
Mailing Address - Country:US
Mailing Address - Phone:740-653-3527
Mailing Address - Fax:740-356-3509
Practice Address - Street 1:1500 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-3478
Practice Address - Country:US
Practice Address - Phone:740-653-3527
Practice Address - Fax:740-356-3509
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-18
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-06-8263-K207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH990006614OtherRAILROAD MEDICARE
OH2021618Medicaid
OH311551850-00OtherWORKERS COMPENSATION
OH358452379OtherTRICARE
OH40888OtherMEDIGOLD
OH5423505OtherAETNA
OH1529613OtherUNITED MINE WORKERS
OH311551850002OtherCIGNA
OH000000121711OtherANTHEM
OH0800909OtherUNITED HEALTH CARE
OH13442OtherNATIONWIDE
OH21149410544-01OtherCAPP CARE
OH311551850-001OtherPRUDENTIAL
OH40888OtherMEDIGOLD
OHG55517Medicare UPIN