Healthcare Provider Details

I. General information

NPI: 1710346671
Provider Name (Legal Business Name): VIDYA KOLLU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2016
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2116 CRAIG RD
EAU CLAIRE WI
54701-6149
US

IV. Provider business mailing address

1345 W CENTRAL PARK AVE
DAVENPORT IA
52804-1844
US

V. Phone/Fax

Practice location:
  • Phone: 715-858-4500
  • Fax:
Mailing address:
  • Phone: 563-421-1900
  • Fax: 563-421-1809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberV0278
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number69007
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberV0278
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD-43419
License Number StateIA
# 5
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number72374
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: