Provider Demographics
NPI:1588411854
Name:BOLLU, BHASWANTH (MD)
Entity type:Individual
Prefix:
First Name:BHASWANTH
Middle Name:
Last Name:BOLLU
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 1:4801 ALBERTA AVE. EL PASO TX 79938 TEXAS TECH HEALTH SC
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905
Mailing Address - Country:US
Mailing Address - Phone:915-215-4116
Mailing Address - Fax:
Practice Address - Street 1:4801 ALBERTA AVE. EL PASO TX 79938 TEXAS TECH HEALTH SC
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905
Practice Address - Country:US
Practice Address - Phone:915-215-4116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-03
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10090519390200000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program