Provider Demographics
NPI:1528162823
Name:POLSTER, PHILLIP (OD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:
Last Name:POLSTER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 W HENDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:PORTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93257
Mailing Address - Country:US
Mailing Address - Phone:559-783-8277
Mailing Address - Fax:
Practice Address - Street 1:1250 W HENDERSON AVE
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257
Practice Address - Country:US
Practice Address - Phone:559-783-8277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACAOPT5319TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0053190Medicaid
CA03275OtherSPECTERA
CA48737OtherSAFEGUARD PPO
CA086510OtherHEALTH NET
CA47023OtherSAFEGUARD HMO
CA6199OtherMEDICAL EYE SERVICES
CASD0053190Medicare ID - Type Unspecified
T09947Medicare UPIN