Provider Demographics
NPI:1225384266
Name:BOLLA, INDERJIT (MD)
Entity type:Individual
Prefix:
First Name:INDERJIT
Middle Name:
Last Name:BOLLA
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 1:77 GOODELL ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1243
Mailing Address - Country:US
Mailing Address - Phone:816-682-3708
Mailing Address - Fax:
Practice Address - Street 1:77 GOODELL ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1243
Practice Address - Country:US
Practice Address - Phone:716-816-7258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-27
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program