Provider Demographics
NPI:1972572360
Name:POLLACK, JONATHAN (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:POLLACK
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 1:701 S NEW BALLAS RD STE 310
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8725
Mailing Address - Country:US
Mailing Address - Phone:314-251-8750
Mailing Address - Fax:314-251-8751
Practice Address - Street 1:701 S NEW BALLAS RD STE 310
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8725
Practice Address - Country:US
Practice Address - Phone:314-251-8750
Practice Address - Fax:314-251-8751
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004002424208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00283056OtherRAILROAD MEDICARE
MO1972572360Medicaid
MOP00283056OtherRAILROAD MEDICARE