Provider Demographics
NPI:1083336283
Name:POLLOCK, MAYA JILLIAN (OD)
Entity Type:Individual
Prefix:
First Name:MAYA
Middle Name:JILLIAN
Last Name:POLLOCK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 W NORTHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-1416
Mailing Address - Country:US
Mailing Address - Phone:612-295-4848
Mailing Address - Fax:920-733-2117
Practice Address - Street 1:1225 W NORTHLAND AVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-1416
Practice Address - Country:US
Practice Address - Phone:920-731-2020
Practice Address - Fax:920-733-2117
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-14
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3817-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist