Healthcare Provider Details

I. General information

NPI: 1437845880
Provider Name (Legal Business Name): TEJASWANNI BOLINENI DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2023
Last Update Date: 04/17/2023
Certification Date: 04/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 E WALNUT ST
LANCASTER OH
43130-4464
US

IV. Provider business mailing address

220 E WALNUT ST
LANCASTER OH
43130-4464
US

V. Phone/Fax

Practice location:
  • Phone: 740-277-6043
  • Fax: 740-689-6759
Mailing address:
  • Phone: 740-277-6043
  • Fax: 740-689-6759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number58.033619
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: