Provider Demographics
NPI:1083699292
Name:POLLER, WAYNE M (DC)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:M
Last Name:POLLER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 N WASHINGTON AVENUE
Mailing Address - Street 2:103
Mailing Address - City:BERGENFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07621
Mailing Address - Country:US
Mailing Address - Phone:201-387-2800
Mailing Address - Fax:201-387-2248
Practice Address - Street 1:136 N WASHINGTON AVENUE
Practice Address - Street 2:103
Practice Address - City:BERGENFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07621
Practice Address - Country:US
Practice Address - Phone:201-387-2800
Practice Address - Fax:201-387-2248
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-09
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00208200111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ350055367OtherRAILROAD MEDICARE
NJ0023792OtherGHI
NJ350055367OtherRAILROAD MEDICARE
NJT45577Medicare UPIN