Provider Demographics
NPI:1376536219
Name:POLEPALLE, CHANDRASEKHAR (MD)
Entity Type:Individual
Prefix:MR
First Name:CHANDRASEKHAR
Middle Name:
Last Name:POLEPALLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3720 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-2141
Mailing Address - Country:US
Mailing Address - Phone:918-683-5989
Mailing Address - Fax:918-688-6690
Practice Address - Street 1:3720 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-2141
Practice Address - Country:US
Practice Address - Phone:918-683-5989
Practice Address - Fax:918-688-6690
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18808207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C47104Medicare UPIN