Healthcare Provider Details

I. General information

NPI: 1982916342
Provider Name (Legal Business Name): VENGAMAMBA POLU MB,BS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2010
Last Update Date: 12/28/2019
Certification Date: 12/28/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 DOCTORS DR STE D
KINSTON NC
28501-1584
US

IV. Provider business mailing address

912 WICKHAM DR
WINTERVILLE NC
28590-9905
US

V. Phone/Fax

Practice location:
  • Phone: 252-559-2200
  • Fax:
Mailing address:
  • Phone: 607-282-0572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number201301694
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: