Provider Demographics
NPI:1811211428
Name:POLISETTY, SUDHEER K (MD)
Entity type:Individual
Prefix:DR
First Name:SUDHEER
Middle Name:K
Last Name:POLISETTY
Suffix:
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 1:5757 MONCLOVA RD STE 26
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1863
Mailing Address - Country:US
Mailing Address - Phone:419-893-5557
Mailing Address - Fax:419-893-5199
Practice Address - Street 1:1800 W CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2386
Practice Address - Country:US
Practice Address - Phone:702-383-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-25
Last Update Date:2025-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV14573207R00000X, 208M00000X
OH35.148982207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist