Provider Demographics
NPI:1215201710
Name:POLANSKY, JERROLD S (MD)
Entity type:Individual
Prefix:DR
First Name:JERROLD
Middle Name:S
Last Name:POLANSKY
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 1:1656 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92106-2127
Mailing Address - Country:US
Mailing Address - Phone:415-577-0750
Mailing Address - Fax:619-222-1868
Practice Address - Street 1:1656 WILLOW ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-2127
Practice Address - Country:US
Practice Address - Phone:415-577-0750
Practice Address - Fax:619-222-1868
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-29
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA445352084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry