Provider Demographics
NPI:1508205857
Name:POLONKA, KATHLEEN D (DO)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:D
Last Name:POLONKA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:D
Other - Last Name:BIGGINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:6626 E 75TH ST STE 500
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7525 E 82ND ST STE B
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1435
Practice Address - Country:US
Practice Address - Phone:317-621-4600
Practice Address - Fax:317-621-4530
Is Sole Proprietor?:No
Enumeration Date:2013-06-20
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5315060478208000000X
IN02004795A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201349120Medicaid