1720414014 NPI number — DR. WILLIAM HOWARD POLONSKY PHD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720414014 NPI number — DR. WILLIAM HOWARD POLONSKY PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLONSKY
Provider First Name:
WILLIAM
Provider Middle Name:
HOWARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720414014
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/19/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2148
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEL MAR
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92014-1448
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-525-5256
Provider Business Mailing Address Fax Number:
760-942-5780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5405 OBERLIN DR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92121-1700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-525-5256
Provider Business Practice Location Address Fax Number:
760-942-5780
Provider Enumeration Date:
09/19/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TH0004X , with the licence number:  PSY13764 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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