=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003072646
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | POLO ALBERTO BANUELOS M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2008
-----------------------------------------------------
Last Update Date | 02/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11212 STATE HIGHWAY 151 MEDICAL PLAZA 1, SUITE 200
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78251-4498
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-520-7160
-----------------------------------------------------
Fax | 210-520-7190
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9730 WESTOVER HILLS BLVD STE 105
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78251-4842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-520-7160
-----------------------------------------------------
Fax | 210-520-7190
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | M9832
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | ME158919
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------