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General NPI Number Information
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NPI Number | 1982148326
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Entity Type | Organization
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Legal Business Name | POLAVARAPU PLASTIC SURGERY, PLLC
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Dates
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Enumeration Date | 12/05/2016
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Last Update Date | 01/31/2017
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Provider Practice Location Address
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Address Line | 4455 CAMP BOWIE BLVD SUITE 114-30
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City | FORT WORTH
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State | TX
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Zip | 76107-3864
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Country | US
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Telephone | 773-710-6128
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Fax |
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Provider Business Mailing Address
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Address Line | 4455 CAMP BOWIE BLVD SUITE 114-30
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City | FORT WORTH
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State | TX
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Zip | 76107-3864
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Country | US
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Telephone | 773-710-6128
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. KIRAN POLAVARAPU
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Credential | M.D.
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Telephone | 817-615-8576
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number | Q0809
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License Number State | TX
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