Provider Demographics
NPI:1275620452
Name:POLKAMPALLY, CHUDAMANI RAO (MD)
Entity Type:Individual
Prefix:DR
First Name:CHUDAMANI
Middle Name:RAO
Last Name:POLKAMPALLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CHUDAMANI
Other - Middle Name:KASUGANTI
Other - Last Name:RAO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:225 COUNTRY CLUB DR STE 140
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7392
Mailing Address - Country:US
Mailing Address - Phone:770-415-5889
Mailing Address - Fax:
Practice Address - Street 1:225 COUNTRY CLUB DR STE 140
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7392
Practice Address - Country:US
Practice Address - Phone:770-415-5889
Practice Address - Fax:770-415-5890
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.009009207R00000X
TXP8066207RN0300X
VA0101241347390200000X
GA74563207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX339316701Medicaid
TXP01393816OtherRRMDCR
TX349292ZCGJLMedicare PIN