Provider Demographics
NPI:1104055185
Name:GOLLAPALLI, VINOD (MD)
Entity type:Individual
Prefix:DR
First Name:VINOD
Middle Name:
Last Name:GOLLAPALLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 S CASTAR DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-4505
Mailing Address - Country:US
Mailing Address - Phone:520-358-4087
Mailing Address - Fax:520-686-7636
Practice Address - Street 1:120 W CALLE DE LAS TIENDAS
Practice Address - Street 2:
Practice Address - City:GREEN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85614-4326
Practice Address - Country:US
Practice Address - Phone:520-990-9960
Practice Address - Fax:520-686-7636
Is Sole Proprietor?:No
Enumeration Date:2009-07-10
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-8752208600000X
NY285906208600000X
AZ53835208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04534938Medicaid