Individual
LAVANYA KOLLURI
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
3132 OLD JACKSONVILLE RD, SPRINGFIELD, IL 62704-7400
(217) 862-0062
(217) 862-0064
Mailing address
3132 OLD JACKSONVILLE RD, SPRINGFIELD, IL 62704-7401
(217) 862-0062
(217) 862-0064
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
01064136A
IN
207R00000X
Internal Medicine Physician
036115509
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
266180960
MEDICARE
IN
05
—
300001136
—
IN
Enumeration date
06/20/2006
Last updated
06/19/2019
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