MEDICARE: DR. PRIYA VINOTHINI COLLURU

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0700X	Prosthodontics	S-714	LA

General Provider Information

NPI Number	:	1376953471
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PRIYA VINOTHINI COLLURU

Provider Business Mailing Address
First Line	:	3913, WHEELER'S STREET
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76111
Country	:	US
Telephone Number	:	682-747-0111
Fax Number	:	504-941-8170

Provider Business Practice Location Address
First Line	:	3913, WHEELER'S STREET
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76111
Country	:	US
Telephone Number	:	682-747-0111
Fax Number	:	504-941-8170

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/29/2014
Last Update Date	:	08/24/2016

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