Provider Demographics
NPI:1790766756
Name:POLAVARAPU, VIJAYALAKSHMI (MD)
Entity Type:Individual
Prefix:
First Name:VIJAYALAKSHMI
Middle Name:
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:PO BOX 616788
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32861-6788
Mailing Address - Country:US
Mailing Address - Phone:407-447-7105
Mailing Address - Fax:407-770-0594
Practice Address - Street 1:6350 W COLONIAL DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32818-7823
Practice Address - Country:US
Practice Address - Phone:407-281-1755
Practice Address - Fax:407-282-6871
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91019207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270395500Medicaid
FLBP8786975OtherDEA
FLBP8786975OtherDEA