Provider Demographics
NPI:1003072646
Name:BANUELOS, POLO ALBERTO (MD)
Entity Type:Individual
Prefix:DR
First Name:POLO
Middle Name:ALBERTO
Last Name:BANUELOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:9730 WESTOVER HILLS BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78251-4842
Mailing Address - Country:US
Mailing Address - Phone:210-520-7160
Mailing Address - Fax:210-520-7190
Practice Address - Street 1:11212 STATE HIGHWAY 151
Practice Address - Street 2:MEDICAL PLAZA 1, SUITE 200
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-4498
Practice Address - Country:US
Practice Address - Phone:210-520-7160
Practice Address - Fax:210-520-7190
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-04
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM98322084N0400X
FLME1589192084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology