Healthcare Provider Details

I. General information

NPI: 1669002697
Provider Name (Legal Business Name): BHUPINDER SINGH BOLLA MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2020
Last Update Date: 01/20/2020
Certification Date: 01/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26561 STATE ROUTE 3 STE A
WATERTOWN NY
13601-1749
US

IV. Provider business mailing address

26561 STATE ROUTE 3 STE A
WATERTOWN NY
13601-1749
US

V. Phone/Fax

Practice location:
  • Phone: 315-782-7246
  • Fax: 315-782-7247
Mailing address:
  • Phone: 315-782-7246
  • Fax: 315-782-7247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: BHUPINDER S BOLLA
Title or Position: OWNER/PROVIDER
Credential:
Phone: 315-782-7246