Provider Demographics
NPI:1427064229
Name:POLTORAK, MACIEJ (MD)
Entity type:Individual
Prefix:
First Name:MACIEJ
Middle Name:
Last Name:POLTORAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:7500 HANOVER PKWY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-2010
Mailing Address - Country:US
Mailing Address - Phone:301-982-7944
Mailing Address - Fax:301-441-8696
Practice Address - Street 1:7500 HANOVER PKWY
Practice Address - Street 2:SUITE 201
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-2010
Practice Address - Country:US
Practice Address - Phone:301-982-7944
Practice Address - Fax:301-441-8696
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2011-06-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MDD548212084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0500456OtherUNITED HEALTHCARE
MD16540016OtherBCBS DC
MD699071100Medicaid
MD298214OtherMAMSI
MD528559OtherAETNA USHC
MDH832NEOtherBCBS MD
MDH832NEOtherBCBS MD
MDH01477Medicare UPIN