Basic Information
| Provider Information | |||||||||
| NPI: | 1790766756 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POLAVARAPU | ||||||||
| FirstName: | VIJAYALAKSHMI | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 616788 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328616788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074477105 | ||||||||
| FaxNumber: | 4077700594 | ||||||||
| Practice Location | |||||||||
| Address1: | 6350 W COLONIAL DR | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328187823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072811755 | ||||||||
| FaxNumber: | 4072826871 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2005 | ||||||||
| LastUpdateDate: | 02/05/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME91019 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 270395500 | 05 | FL | MEDICAID | BP8786975 | 01 | FL | DEA | OTHER |