Provider Demographics
NPI:1770996027
Name:POLAVARAPU, ABHISHEK DATTA (MD)
Entity type:Individual
Prefix:
First Name:ABHISHEK
Middle Name:DATTA
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 1:1125 N PORTER AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-6443
Mailing Address - Country:US
Mailing Address - Phone:405-515-2777
Mailing Address - Fax:405-515-2780
Practice Address - Street 1:1125 N PORTER AVE STE 301
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-6443
Practice Address - Country:US
Practice Address - Phone:405-515-2777
Practice Address - Fax:405-515-2780
Is Sole Proprietor?:No
Enumeration Date:2014-06-04
Last Update Date:2021-07-21
Deactivation Date:2015-01-07
Deactivation Code:
Reactivation Date:2015-03-13
Provider Licenses
StateLicense IDTaxonomies
244202390200000X
OK38145207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program