Provider Demographics
NPI:1528065893
Name:KOLLURU, RAMACHANDRA (MD)
Entity type:Individual
Prefix:
First Name:RAMACHANDRA
Middle Name:
Last Name:KOLLURU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RAMACHANDRA
Other - Middle Name:RAO
Other - Last Name:KOLLURU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
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 1:420E6TH STREET
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4537
Practice Address - Country:US
Practice Address - Phone:432-685-3333
Practice Address - Fax:432-570-5440
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2015-10-21
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
TXJ0555207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX135590104Medicaid
TX80W060Medicare PIN
TXE88405Medicare UPIN