Provider Demographics
NPI:1942294863
Name:POLK, DONALD GABRIEL (DO)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:GABRIEL
Last Name:POLK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:D.
Other - Middle Name:GABRIEL
Other - Last Name:POLK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:2717 EAST OAKLAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1843
Mailing Address - Country:US
Mailing Address - Phone:423-926-2358
Mailing Address - Fax:423-926-2680
Practice Address - Street 1:103 JV MANGUBAT DR
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:TN
Practice Address - Zip Code:38485-2440
Practice Address - Country:US
Practice Address - Phone:931-762-9418
Practice Address - Fax:931-722-9081
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO1538207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN33079841Medicaid
TNH90351Medicare UPIN
TN33079841Medicaid
TN3307986Medicare ID - Type Unspecified