Provider Demographics
NPI:1366479982
Name:BOLLAVARAM, KAVITA VANGURU (MD)
Entity type:Individual
Prefix:
First Name:KAVITA
Middle Name:VANGURU
Last Name:BOLLAVARAM
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 1:2224 GLENMORE LN
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-5650
Mailing Address - Country:US
Mailing Address - Phone:770-985-1870
Mailing Address - Fax:
Practice Address - Street 1:VA CLINIC
Practice Address - Street 2:1970 RIVERSIDE PARKWAY
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043
Practice Address - Country:US
Practice Address - Phone:404-417-1713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047575207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine