Provider Demographics
NPI:1447633326
Name:POLYAKOVA, IRYNA VITALIYIVNA (DO)
Entity type:Individual
Prefix:DR
First Name:IRYNA
Middle Name:VITALIYIVNA
Last Name:POLYAKOVA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:1201 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-8481
Practice Address - Country:US
Practice Address - Phone:219-738-2100
Practice Address - Fax:219-933-2288
Is Sole Proprietor?:No
Enumeration Date:2015-07-09
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS15044207Q00000X
IN02006069A207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLJK466OtherFL MEDICARE
FLP02211193OtherFL RR MEDICARE