Healthcare Provider Details

I. General information

NPI: 1073515987
Provider Name (Legal Business Name): PRAVEEN KOLLIPARA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 05/15/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7910 W JEFFERSON BLVD STE 108
FORT WAYNE IN
46804-4159
US

IV. Provider business mailing address

PO BOX 749495
ATLANTA GA
30374-9495
US

V. Phone/Fax

Practice location:
  • Phone: 260-484-8830
  • Fax: 260-483-1911
Mailing address:
  • Phone: 855-963-2100
  • Fax: 239-236-2775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number01046718A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number01046718A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: