Provider Demographics
NPI:1437115797
Name:POLK, JOHN CHARLES (PT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CHARLES
Last Name:POLK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4650 EVERHART RD
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-2746
Mailing Address - Country:US
Mailing Address - Phone:361-993-1173
Mailing Address - Fax:361-994-1110
Practice Address - Street 1:4650 EVERHART RD
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-2746
Practice Address - Country:US
Practice Address - Phone:361-993-1173
Practice Address - Fax:361-994-1110
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1002855225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXR69314Medicare UPIN
TX650086Medicare ID - Type Unspecified