Provider Demographics
NPI:1710123088
Name:NIRAVATH, POLLY (MD)
Entity Type:Individual
Prefix:
First Name:POLLY
Middle Name:
Last Name:NIRAVATH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6445 MAIN STREET
Mailing Address - Street 2:OPC 24
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030
Mailing Address - Country:US
Mailing Address - Phone:713-441-9948
Mailing Address - Fax:
Practice Address - Street 1:6445 MAIN STREET
Practice Address - Street 2:OPC 24
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030
Practice Address - Country:US
Practice Address - Phone:713-441-9948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-17
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM8217207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX284968905Medicaid