Healthcare Provider Details

I. General information

NPI: 1730312877
Provider Name (Legal Business Name): RAHUL REDDY KOLAVALA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2009
Last Update Date: 12/02/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 LA JOLLA VILLAGE DR
SAN DIEGO CA
92161-0002
US

IV. Provider business mailing address

3350 LA JOLLA VILLAGE DR
SAN DIEGO CA
92161-0002
US

V. Phone/Fax

Practice location:
  • Phone: 858-552-8585
  • Fax:
Mailing address:
  • Phone: 858-552-8585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number036.126963
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: