Provider Demographics
NPI:1194798983
Name:POLVERINO, EDWIN J (DO)
Entity type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:J
Last Name:POLVERINO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1935 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-3109
Practice Address - Country:US
Practice Address - Phone:540-387-0441
Practice Address - Fax:540-389-7868
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102037045207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005622191Medicaid
VA080007743Medicare ID - Type UnspecifiedPROVIDER ID
VA005622191Medicaid