Provider Demographics
NPI:1831260256
Name:CUNNINGHAM, POLLA SUE (MD)
Entity type:Individual
Prefix:
First Name:POLLA
Middle Name:SUE
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 MAR WALT DRIVE
Mailing Address - Street 2:ADMINISTRATION
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6796
Mailing Address - Country:US
Mailing Address - Phone:850-863-8100
Mailing Address - Fax:850-862-2303
Practice Address - Street 1:1005 MAR WALT DRIVE
Practice Address - Street 2:ADMINISTRATION
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6796
Practice Address - Country:US
Practice Address - Phone:850-863-8100
Practice Address - Fax:850-862-2303
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94647207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL101581Medicaid
FL41131OtherBCBS
FL278157300Medicaid
FL7773615OtherAETNA
FL41131OtherBCBS
AZI05857Medicare UPIN
AL101581Medicaid