Healthcare Provider Details

I. General information

NPI: 1093403438
Provider Name (Legal Business Name): SOUMYA LAKSHMI POLAVARAPU DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2023
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 MONTOPOLIS DR
AUSTIN TX
78741-6411
US

IV. Provider business mailing address

1501 RED RIVER ST FL 2
AUSTIN TX
78712-1845
US

V. Phone/Fax

Practice location:
  • Phone: 512-978-9901
  • Fax:
Mailing address:
  • Phone: 512-495-5555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number823271
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: