Provider Demographics
NPI:1063640019
Name:POLYAKOV, INNA (MD)
Entity Type:Individual
Prefix:DR
First Name:INNA
Middle Name:
Last Name:POLYAKOV
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 WALNUT ST APT 505
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5449
Mailing Address - Country:US
Mailing Address - Phone:757-636-6067
Mailing Address - Fax:
Practice Address - Street 1:1200 WALNUT ST APT 505
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5449
Practice Address - Country:US
Practice Address - Phone:757-636-6067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-29
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA195244390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program