Provider Demographics
NPI:1942205299
Name:POLK, DAN G (PHD)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:G
Last Name:POLK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6750 WEST LOOP S
Mailing Address - Street 2:STE 1000
Mailing Address - City:BELLAIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77401-4105
Mailing Address - Country:US
Mailing Address - Phone:713-628-4700
Mailing Address - Fax:
Practice Address - Street 1:6750 WEST LOOP S
Practice Address - Street 2:STE 1000
Practice Address - City:BELLAIRE
Practice Address - State:TX
Practice Address - Zip Code:77401-4105
Practice Address - Country:US
Practice Address - Phone:713-628-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-14
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-5565103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX122378602Medicaid
TX0091DZOtherBLUE CROSS BLUE SHIELD
TX122378602Medicaid