Provider Demographics
NPI:1447318696
Name:POLK, RUSSEL W (DC)
Entity type:Individual
Prefix:DR
First Name:RUSSEL
Middle Name:W
Last Name:POLK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:14370 W STATE HWY 29
Mailing Address - Street 2:SUITE 6
Mailing Address - City:LIBERTY HILL
Mailing Address - State:TX
Mailing Address - Zip Code:78642-5795
Mailing Address - Country:US
Mailing Address - Phone:512-778-9009
Mailing Address - Fax:512-778-9059
Practice Address - Street 1:14370 W STATE HWY 29
Practice Address - Street 2:SUITE 6
Practice Address - City:LIBERTY HILL
Practice Address - State:TX
Practice Address - Zip Code:78642-5795
Practice Address - Country:US
Practice Address - Phone:512-778-9009
Practice Address - Fax:512-778-9059
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX2999111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT15327Medicare UPIN
TX603836Medicare PIN