Provider Demographics
NPI:1316464134
Name:POLACCO, AMANDA (OD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:POLACCO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 MARTIN LUTHER KING BLVD.
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77204-2020
Mailing Address - Country:US
Mailing Address - Phone:713-743-2020
Mailing Address - Fax:713-743-0963
Practice Address - Street 1:4401 MARTIN LUTHER KING BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77204-2020
Practice Address - Country:US
Practice Address - Phone:713-743-2020
Practice Address - Fax:713-743-0963
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008677152W00000X
TX10375152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00244528Medicaid
TX429762401Medicaid