Provider Demographics
NPI:1376711291
Name:POLISETTY, PRASAD (MD)
Entity Type:Individual
Prefix:DR
First Name:PRASAD
Middle Name:
Last Name:POLISETTY
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 1:204 TIMBER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-3655
Mailing Address - Country:US
Mailing Address - Phone:248-633-4262
Mailing Address - Fax:
Practice Address - Street 1:204 TIMBER RIDGE DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3655
Practice Address - Country:US
Practice Address - Phone:248-633-4262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-13
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301090287207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine