Provider Demographics
NPI:1720167232
Name:POLAVARAPU, RAGHAVA RAO (MD)
Entity Type:Individual
Prefix:DR
First Name:RAGHAVA
Middle Name:RAO
Last Name:POLAVARAPU
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 1:26 SUNSET RD W
Mailing Address - Street 2:
Mailing Address - City:ALBERTSON
Mailing Address - State:NY
Mailing Address - Zip Code:11507-1115
Mailing Address - Country:US
Mailing Address - Phone:516-621-0346
Mailing Address - Fax:718-398-3104
Practice Address - Street 1:26 SUNSET RD W
Practice Address - Street 2:
Practice Address - City:ALBERTSON
Practice Address - State:NY
Practice Address - Zip Code:11507-1115
Practice Address - Country:US
Practice Address - Phone:516-621-0346
Practice Address - Fax:718-398-3104
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY126244207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00248435Medicaid
NY126244OtherLICENSE
NY00248435Medicaid
CO8452Medicare UPIN
NY322251Medicare ID - Type Unspecified