Provider Demographics
NPI:1003974767
Name:POLAK, CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:POLAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:328 W SAINT GEORGES AVE
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07036-5638
Mailing Address - Country:US
Mailing Address - Phone:908-925-7519
Mailing Address - Fax:908-925-2842
Practice Address - Street 1:328 W SAINT GEORGES AVE
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:NJ
Practice Address - Zip Code:07036-5638
Practice Address - Country:US
Practice Address - Phone:908-925-7519
Practice Address - Fax:908-925-2842
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03464300170100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical Genetics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC08389Medicare UPIN