Provider Demographics
NPI:1962476762
Name:POLON, CLIVE (MD)
Entity Type:Individual
Prefix:DR
First Name:CLIVE
Middle Name:
Last Name:POLON
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 1:1601 TRINITY ST STOP Z0200
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78712-1850
Mailing Address - Country:US
Mailing Address - Phone:512-495-5512
Mailing Address - Fax:
Practice Address - Street 1:900 E 30TH ST
Practice Address - Street 2:SUITE 107
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-3326
Practice Address - Country:US
Practice Address - Phone:512-476-9699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-16
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1001207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0035BJOtherBCBS PROVIDER ID
TX10007154OtherAMERIGROUP PROVIDER ID
TX113461103Medicaid
TX0035BJMedicare ID - Type Unspecified