Provider Demographics
NPI:1497749790
Name:POLHAMUS, CLINTON D (MD)
Entity type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:D
Last Name:POLHAMUS
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 1:1804 NE LOOP 410
Mailing Address - Street 2:#101
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-5211
Mailing Address - Country:US
Mailing Address - Phone:210-828-8400
Mailing Address - Fax:210-804-4454
Practice Address - Street 1:1804 NE LOOP 410
Practice Address - Street 2:#101
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-5211
Practice Address - Country:US
Practice Address - Phone:210-828-8400
Practice Address - Fax:210-804-4454
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE8822207RG0100X
TXG2539207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114369504Medicaid
TX8C9489Medicare ID - Type Unspecified
TX114369504Medicaid