Healthcare Provider Details

I. General information

NPI: 1487842696
Provider Name (Legal Business Name): LEELA R BOLLA MD MEDICAL ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2007
Last Update Date: 07/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1890 SW HEALTH PKWY SUITE #100
NAPLES FL
34109-0473
US

IV. Provider business mailing address

1890 SW HEALTH PKWY SUITE #100
NAPLES FL
34109-0473
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: DR. LEELA R BOLLA
Title or Position: OWNER
Credential: M.D.
Phone: 239-597-0544