Provider Demographics
NPI:1386735777
Name:POLSKIY, PAVEL (MD)
Entity type:Individual
Prefix:
First Name:PAVEL
Middle Name:
Last Name:POLSKIY
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 1:5810 JAMESON CT
Mailing Address - Street 2:STE 1
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608
Mailing Address - Country:US
Mailing Address - Phone:916-979-0621
Mailing Address - Fax:916-979-1110
Practice Address - Street 1:5810 JAMESON CT
Practice Address - Street 2:STE 1
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608
Practice Address - Country:US
Practice Address - Phone:916-979-0621
Practice Address - Fax:916-979-1110
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA84409207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A844090Medicaid
CA00A844090Medicare ID - Type Unspecified
CA00A844090Medicaid