Provider Demographics
NPI:1811211428
Name:POLISETTY, SUDHEER K (MD)
Entity Type:Individual
Prefix:DR
First Name:SUDHEER
Middle Name:K
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 1:7330 NIGHTINGALE DR APT 8
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:OH
Mailing Address - Zip Code:43528-9316
Mailing Address - Country:US
Mailing Address - Phone:702-912-8494
Mailing Address - Fax:
Practice Address - Street 1:3355 GLENDALE AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-2426
Practice Address - Country:US
Practice Address - Phone:419-383-5547
Practice Address - Fax:419-383-5515
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-25
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV14573207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine