Healthcare Provider Details

I. General information

NPI: 1174025647
Provider Name (Legal Business Name): RYAN WILLIAM POLSTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2018
Last Update Date: 10/03/2025
Certification Date: 10/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 ROGER BROOKE DR
JBSA FT SAM HOUSTON TX
78234-4504
US

IV. Provider business mailing address

3551 ROGER BROOKE DR
JBSA FT SAM HOUSTON TX
78234-4504
US

V. Phone/Fax

Practice location:
  • Phone: 210-916-2153
  • Fax: 210-916-0709
Mailing address:
  • Phone: 210-916-2153
  • Fax: 210-916-0709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number61227551
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: