Provider Demographics
NPI:1114907391
Name:POLHEMUS, ILENE BETH (OD)
Entity Type:Individual
Prefix:DR
First Name:ILENE
Middle Name:BETH
Last Name:POLHEMUS
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 1:15563 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-3904
Mailing Address - Country:US
Mailing Address - Phone:408-377-2020
Mailing Address - Fax:408-377-2022
Practice Address - Street 1:15563 UNION AVE
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-3904
Practice Address - Country:US
Practice Address - Phone:408-377-2020
Practice Address - Fax:408-377-2022
Is Sole Proprietor?:No
Enumeration Date:2006-01-22
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11037T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU75699Medicare UPIN
CASDO110370Medicare ID - Type Unspecified