Healthcare Provider Details

I. General information

NPI: 1275641326
Provider Name (Legal Business Name): LEELA R BOLLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 03/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1890 SW HEALTH PARKWAY SUITE 100
NAPLES FL
34109-0421
US

IV. Provider business mailing address

1890 SW HEALTH PARKWAY SUITE 100
NAPLES FL
34109-0421
US

V. Phone/Fax

Practice location:
  • Phone: 239-597-0544
  • Fax: 239-597-8644
Mailing address:
  • Phone: 239-597-0544
  • Fax: 239-597-8644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberME79879
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: