Provider Demographics
NPI:1285794289
Name:RAM KOLLURU,M.D.PA
Entity type:Organization
Organization Name:RAM KOLLURU,M.D.PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAMACHANDRA
Authorized Official - Middle Name:RAO
Authorized Official - Last Name:KOLLURU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:432-685-3333
Mailing Address - Street 1:5 SANTA MARIA CT
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79765-8515
Mailing Address - Country:US
Mailing Address - Phone:432-685-3333
Mailing Address - Fax:432-570-5440
Practice Address - Street 1:420 E 6TH ST
Practice Address - Street 2:STE 102
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4529
Practice Address - Country:US
Practice Address - Phone:432-685-3333
Practice Address - Fax:432-570-5440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX109508502Medicaid
TX109508502Medicaid