Provider Demographics
NPI:1417418260
Name:POLAMRAJU, PRAVEEN VENKATA
Entity Type:Individual
Prefix:
First Name:PRAVEEN
Middle Name:VENKATA
Last Name:POLAMRAJU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 E ANDERSON ST
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-5705
Mailing Address - Country:US
Mailing Address - Phone:940-395-6666
Mailing Address - Fax:
Practice Address - Street 1:713 E ANDERSON ST
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-5705
Practice Address - Country:US
Practice Address - Phone:940-395-6666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-26
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty