Healthcare Provider Details

I. General information

NPI: 1639353139
Provider Name (Legal Business Name): MAMATHA BOLLINENI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MAMATHA BOLLINENI M.D.

II. Dates (important events)

Enumeration Date: 12/20/2007
Last Update Date: 08/01/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W DEAN KEETON ST CAMPUS MAIL A3900 (UHS)
AUSTIN TX
78731
US

IV. Provider business mailing address

100 W DEAN KEETON ST CAMPUS MAIL A3900 (UHS)
AUSTIN TX
78731
US

V. Phone/Fax

Practice location:
  • Phone: 512-475-8252
  • Fax: 512-219-0733
Mailing address:
  • Phone: 512-475-8252
  • Fax: 512-219-0733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number246435
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberQ1951
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: