Healthcare Provider Details

I. General information

NPI: 1376536219
Provider Name (Legal Business Name): CHANDRASEKHAR POLEPALLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3720 W BROADWAY ST
MUSKOGEE OK
74401-2141
US

IV. Provider business mailing address

3720 W BROADWAY ST
MUSKOGEE OK
74401-2141
US

V. Phone/Fax

Practice location:
  • Phone: 918-683-5989
  • Fax: 918-688-6690
Mailing address:
  • Phone: 918-683-5989
  • Fax: 918-688-6690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number18808
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: