Provider Demographics
NPI:1982148326
Name:POLAVARAPU PLASTIC SURGERY, PLLC
Entity Type:Organization
Organization Name:POLAVARAPU PLASTIC SURGERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:POLAVARAPU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-615-8576
Mailing Address - Street 1:4455 CAMP BOWIE BLVD
Mailing Address - Street 2:SUITE 114-30
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-3864
Mailing Address - Country:US
Mailing Address - Phone:773-710-6128
Mailing Address - Fax:
Practice Address - Street 1:4455 CAMP BOWIE BLVD
Practice Address - Street 2:SUITE 114-30
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-3864
Practice Address - Country:US
Practice Address - Phone:773-710-6128
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-05
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ0809208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty