Provider Demographics
NPI:1285009803
Name:POLK, KENDALL (CSFA)
Entity Type:Individual
Prefix:
First Name:KENDALL
Middle Name:
Last Name:POLK
Suffix:
Gender:M
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3540 E. BRAOD ST. STE 102#237
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-9157
Mailing Address - Country:US
Mailing Address - Phone:214-927-6539
Mailing Address - Fax:817-394-1231
Practice Address - Street 1:205 CRENSHAW DR
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-3451
Practice Address - Country:US
Practice Address - Phone:214-927-6539
Practice Address - Fax:817-394-1231
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-08
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00635246ZS0410X, 208600000X, 246ZX2200X, 246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No246ZX2200XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherOrthopedic Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1225495708OtherNPI