Provider Demographics
NPI:1508814807
Name:POLATIN, PETER BARTH (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:BARTH
Last Name:POLATIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 MAPLE AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-6519
Mailing Address - Country:US
Mailing Address - Phone:214-351-6600
Mailing Address - Fax:
Practice Address - Street 1:5701 MAPLE AVE
Practice Address - Street 2:STE 100
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-6519
Practice Address - Country:US
Practice Address - Phone:214-351-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMDG91902084P2900X
DCMD039126261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain Medicine
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126618102Medicaid
TXB25577Medicare UPIN
TX126618102Medicaid