MEDICARE: DR. KALYANI POLANI RAJA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	K1287	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770586505
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KALYANI POLANI RAJA M.D.

Provider Business Mailing Address
First Line	:	7679 PICTON DR
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75063-1258
Country	:	US
Telephone Number	:	214-532-7206
Fax Number	:	142-227-9996

Provider Business Practice Location Address
First Line	:	7679 PICTON DR
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75063-1258
Country	:	US
Telephone Number	:	214-532-7206
Fax Number	:	214-227-9996

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	10/31/2022

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