Provider Demographics
NPI:1073584389
Name:POLISETTY, USHA S (MD)
Entity Type:Individual
Prefix:
First Name:USHA
Middle Name:S
Last Name:POLISETTY
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:PO BOX 1071
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41702-9483
Mailing Address - Country:US
Mailing Address - Phone:859-497-7781
Mailing Address - Fax:859-497-6017
Practice Address - Street 1:50 STERLING AVE
Practice Address - Street 2:BOX 7
Practice Address - City:MT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353-1100
Practice Address - Country:US
Practice Address - Phone:859-497-7781
Practice Address - Fax:859-497-6017
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY23824174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64238249Medicaid
KY1404301Medicare ID - Type Unspecified
KY64238249Medicaid