Basic Information
| Provider Information | |||||||||
| NPI: | 1942294863 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLK | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | GABRIEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | POLK | ||||||||
| OtherFirstName: | D. | ||||||||
| OtherMiddleName: | GABRIEL | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 103 JV MANGUBAT DR | ||||||||
| Address2: | |||||||||
| City: | WAYNESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384852440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317225411 | ||||||||
| FaxNumber: | 9317229081 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 JV MANGUBAT DR | ||||||||
| Address2: | |||||||||
| City: | WAYNESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384852440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317225411 | ||||||||
| FaxNumber: | 9317229081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2005 | ||||||||
| LastUpdateDate: | 12/27/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | DO1538 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 33079841 | 05 | TN | MEDICAID |