Provider Demographics
NPI:1053390013
Name:POLK, HENRY LYSELL JR (MD)
Entity type:Individual
Prefix:DR
First Name:HENRY
Middle Name:LYSELL
Last Name:POLK
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:17503 LACANTERA PARKWAY
Mailing Address - Street 2:104 BOX 485
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78257-8207
Mailing Address - Country:US
Mailing Address - Phone:210-495-3627
Mailing Address - Fax:210-491-3581
Practice Address - Street 1:8550 HUEBNER RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-1803
Practice Address - Country:US
Practice Address - Phone:210-541-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXM75292084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8K4205Medicare UPIN