Healthcare Provider Details

I. General information

NPI: 1316994148
Provider Name (Legal Business Name): SRIDHAR REDDY BOLLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 09/17/2020
Certification Date: 09/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8244 E US HIGHWAY 36 STE 1340
AVON IN
46123-9688
US

IV. Provider business mailing address

8244 E US HIGHWAY 36 STE 1340
AVON IN
46123-9688
US

V. Phone/Fax

Practice location:
  • Phone: 317-520-5510
  • Fax: 317-386-5539
Mailing address:
  • Phone: 317-520-5510
  • Fax: 317-386-5539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number01059289A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: