Provider Demographics
NPI:1174623508
Name:KOLLI, SUDHA R (MD)
Entity type:Individual
Prefix:MRS
First Name:SUDHA
Middle Name:R
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 1:262 LIVINGSTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901-3058
Mailing Address - Country:US
Mailing Address - Phone:732-249-2044
Mailing Address - Fax:732-790-2626
Practice Address - Street 1:262 LIVINGSTON AVE
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-3058
Practice Address - Country:US
Practice Address - Phone:732-249-2044
Practice Address - Fax:732-790-2626
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA69513207RG0300X
NJ25MA06951300207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8181705Medicaid
NJ036601Medicare PIN
NJ8181705Medicaid