Provider Demographics
NPI:1376536862
Name:POLAVARAPU, PADMAJA PAM (MD)
Entity Type:Individual
Prefix:MRS
First Name:PADMAJA
Middle Name:PAM
Last Name:POLAVARAPU
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 1:1810 59TH ST W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-4630
Mailing Address - Country:US
Mailing Address - Phone:941-792-1412
Mailing Address - Fax:941-795-0753
Practice Address - Street 1:1810 59TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-4630
Practice Address - Country:US
Practice Address - Phone:941-792-1412
Practice Address - Fax:941-795-0753
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME108341174400000X
WV17433207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV007822100OtherMEDICAID
VA006048641Medicaid
FLF0962ZMedicare UPIN
VA006048641Medicaid