Healthcare Provider Details

I. General information

NPI: 1053390013
Provider Name (Legal Business Name): HENRY LYSELL POLK JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 02/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8550 HUEBNER RD
SAN ANTONIO TX
78240-1803
US

IV. Provider business mailing address

17503 LACANTERA PARKWAY 104 BOX 485
SAN ANTONIO TX
78257-8207
US

V. Phone/Fax

Practice location:
  • Phone: 210-541-5300
  • Fax:
Mailing address:
  • Phone: 210-495-3627
  • Fax: 210-491-3581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberM7529
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: