Healthcare Provider Details

I. General information

NPI: 1770996027
Provider Name (Legal Business Name): ABHISHEK DATTA POLAVARAPU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2014
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date: 01/07/2015
Reactivation Date: 03/13/2015

III. Provider practice location address

6160 S YALE AVE FL 1
TULSA OK
74136-1930
US

IV. Provider business mailing address

PO BOX 636256
CINCINNATI OH
45263-6256
US

V. Phone/Fax

Practice location:
  • Phone: 918-497-3300
  • Fax: 918-497-3365
Mailing address:
  • Phone: 513-585-6200
  • Fax: 513-245-3672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number35.153053
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number38145
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number244202
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: