Provider Demographics
NPI:1083696462
Name:POLEK, VINCENT S (MD)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:S
Last Name:POLEK
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:PO BOX 15718
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92623-5718
Mailing Address - Country:US
Mailing Address - Phone:949-263-8620
Mailing Address - Fax:949-263-1639
Practice Address - Street 1:3751 KATELLA AVE
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90702
Practice Address - Country:US
Practice Address - Phone:562-799-3294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-19
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG585252085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G585250Medicaid
CA00G585250OtherBLUE SHIELD
E97881Medicare UPIN
CA00G585250OtherBLUE SHIELD
CA00G585250Medicaid