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General NPI Number Information
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NPI Number | 1770580631
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Entity Type | Individual
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Provider Name | SAMRAJYAM KOLLURU MD
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Gender | Female
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Dates
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Enumeration Date | 07/06/2005
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 621 N WASHINGTON AVE
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City | ODESSA
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State | TX
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Zip | 79761-4436
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Country | US
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Telephone | 432-580-9999
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Fax | 432-580-5051
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Provider Business Mailing Address
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Address Line | 5 SANTA MARIA CT
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City | ODESSA
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State | TX
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Zip | 79765-8515
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Country | US
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Telephone | 432-272-5852
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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 | 174400000X
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Taxonomy Name | Specialist
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License Number | H9663
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License Number State | TX
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