Provider Demographics
NPI:1144231374
Name:POLK, OCTAVIUS DOUGLAS JR (MD)
Entity type:Individual
Prefix:DR
First Name:OCTAVIUS
Middle Name:DOUGLAS
Last Name:POLK
Suffix:JR
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 1:12800 LIBERTYS DELIGHT DR UNIT 104
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-6347
Mailing Address - Country:US
Mailing Address - Phone:240-476-9795
Mailing Address - Fax:202-526-5434
Practice Address - Street 1:251 NATIONAL HARBOR BLVD
Practice Address - Street 2:5TH FLOOR
Practice Address - City:OXON HILL
Practice Address - State:MD
Practice Address - Zip Code:20745
Practice Address - Country:US
Practice Address - Phone:301-618-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC12239207RP1001X
MDD31941207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC011651200Medicaid
DC011651200Medicaid