=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104055185
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VINOD GOLLAPALLI MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2009
-----------------------------------------------------
Last Update Date | 09/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 W CALLE DE LAS TIENDAS
-----------------------------------------------------
City | GREEN VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85614-4326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-990-9960
-----------------------------------------------------
Fax | 520-686-7636
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1160 S CASTAR DR
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85745-4505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-358-4087
-----------------------------------------------------
Fax | 520-686-7636
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | R-8752
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 285906
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 53835
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------