Healthcare Provider Details

I. General information

NPI: 1376536862
Provider Name (Legal Business Name): PADMAJA PAM POLAVARAPU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 03/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 59TH ST W
BRADENTON FL
34209-4630
US

IV. Provider business mailing address

1810 59TH ST W
BRADENTON FL
34209-4630
US

V. Phone/Fax

Practice location:
  • Phone: 941-792-1412
  • Fax: 941-795-0753
Mailing address:
  • Phone: 941-792-1412
  • Fax: 941-795-0753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME108341
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number17433
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: