Provider Demographics
NPI:1164494134
Name:POLK, ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:POLK
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 1:2724 CRYSTAL SPRING AVE SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-2322
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:46 WESLEY RD
Practice Address - Street 2:
Practice Address - City:DALEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24083-3082
Practice Address - Country:US
Practice Address - Phone:540-992-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-055456207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005636655Medicaid
VA5637791Medicaid
VA5637783Medicaid
VA005636655Medicaid
VA5637783Medicaid
VAG66000Medicare UPIN
011424C04Medicare PIN