=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366699233
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MADHAVI LATHA KOLLA MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2008
-----------------------------------------------------
Last Update Date | 02/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 275 CASTLETON AVE
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10301-2709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-489-8176
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 55 FOUR CORNERS RD
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10304-1217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-423-4206
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 249792-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------