Provider Demographics
NPI:1366699233
Name:KOLLA, MADHAVI LATHA (MD)
Entity type:Individual
Prefix:DR
First Name:MADHAVI
Middle Name:LATHA
Last Name:KOLLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MADHAVI
Other - Middle Name:LATHA
Other - Last Name:KOLLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:55 FOUR CORNERS RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-1217
Mailing Address - Country:US
Mailing Address - Phone:201-423-4206
Mailing Address - Fax:
Practice Address - Street 1:275 CASTLETON AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-2709
Practice Address - Country:US
Practice Address - Phone:718-489-8176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-22
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY249792-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine