Provider Demographics
NPI:1316994148
Name:BOLLA, SRIDHAR REDDY (MD)
Entity type:Individual
Prefix:DR
First Name:SRIDHAR
Middle Name:REDDY
Last Name:BOLLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8244 E US HIGHWAY 36 STE 1340
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-9688
Mailing Address - Country:US
Mailing Address - Phone:317-520-5510
Mailing Address - Fax:317-386-5539
Practice Address - Street 1:8244 E US HIGHWAY 36 STE 1340
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-9688
Practice Address - Country:US
Practice Address - Phone:317-520-5510
Practice Address - Fax:317-386-5539
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059289A207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000380791OtherANTHEM
IN200336270Medicaid
IN000000380791OtherANTHEM
ING93931Medicare UPIN
IN200336270Medicaid
P00401857Medicare PIN