Provider Demographics
NPI:1174617625
Name:KOLLA, RATNAVALI (MD)
Entity type:Individual
Prefix:DR
First Name:RATNAVALI
Middle Name:
Last Name:KOLLA
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 1:16003 COMPRINT CIRCLE
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-1318
Mailing Address - Country:US
Mailing Address - Phone:301-869-2358
Mailing Address - Fax:301-593-1061
Practice Address - Street 1:16003 COMPRINT CIR
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-1318
Practice Address - Country:US
Practice Address - Phone:301-869-2358
Practice Address - Fax:301-593-1061
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0061502174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC039326600Medicaid
MD413840600Medicaid
DCG02802C01Medicare PIN
MDI15550Medicare UPIN