Healthcare Provider Details

I. General information

NPI: 1588047484
Provider Name (Legal Business Name): SHALINI GOLLA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2015
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1733 LAKELAND HILLS BLVD
LAKELAND FL
33805-3016
US

IV. Provider business mailing address

PO BOX 748817
ATLANTA GA
30374-8817
US

V. Phone/Fax

Practice location:
  • Phone: 863-688-1528
  • Fax: 863-688-8423
Mailing address:
  • Phone: 813-286-0333
  • Fax: 813-282-1806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME138962
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: