MEDICARE: DONNA MAE DIVINA POLIQUIT M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	Q1477	TX

General Provider Information

NPI Number	:	1881882835
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONNA MAE DIVINA POLIQUIT M.D.

Provider Business Mailing Address
First Line	:	PO BOX 733784
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75373-3784
Country	:	US
Telephone Number	:	682-885-1855
Fax Number	:	682-885-1396

Provider Business Practice Location Address
First Line	:	1525 S COOPER ST
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76010-4105
Country	:	US
Telephone Number	:	817-804-1100
Fax Number	:	817-299-8790

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2007
Last Update Date	:	05/13/2021

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