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General NPI Number Information
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NPI Number | 1386801652
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Entity Type | Individual
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Provider Name | PRADEEP GOLLA D.O
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Gender | Male
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Dates
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Enumeration Date | 05/22/2008
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Last Update Date | 10/11/2012
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Provider Practice Location Address
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Address Line | 3131 MEMORIAL CT APT 12104
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City | HOUSTON
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State | TX
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Zip | 77007-6255
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Country | US
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Telephone | 312-490-9388
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Fax |
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Provider Business Mailing Address
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Address Line | 3131 MEMORIAL CT APT 12104
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City | HOUSTON
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State | TX
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Zip | 77007-6255
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Country | US
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Telephone | 312-490-9388
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | 39
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License Number State | NJ
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Taxonomy #2
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 036.125014
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License Number State | IL
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