Provider Demographics
NPI:1538384532
Name:POLSON, MICHAEL CLARK (DC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:CLARK
Last Name:POLSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 BROAD PARK CIRCLE SOUTH
Mailing Address - Street 2:STE 302
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063
Mailing Address - Country:US
Mailing Address - Phone:817-473-1849
Mailing Address - Fax:817-473-6016
Practice Address - Street 1:1750 BROAD PARK CIRCLE SOUTH
Practice Address - Street 2:STE 302
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063
Practice Address - Country:US
Practice Address - Phone:817-473-1849
Practice Address - Fax:817-473-6016
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4024111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX601458Medicare UPIN