Healthcare Provider Details

I. General information

NPI: 1346250800
Provider Name (Legal Business Name): MANGARAJU KOLLURU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 09/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 RIVER RD
SELMA NC
27576-3611
US

IV. Provider business mailing address

1101 RIVER RD
SELMA NC
27576-3611
US

V. Phone/Fax

Practice location:
  • Phone: 919-965-9655
  • Fax: 919-975-1029
Mailing address:
  • Phone: 919-965-6550
  • Fax: 919-975-1029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number26290
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number26290
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: