Provider Demographics
NPI:1114912532
Name:POLIS, CHARLES T JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:T
Last Name:POLIS
Suffix:JR
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 1:1410 59TH ST W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-4607
Mailing Address - Country:US
Mailing Address - Phone:941-792-1477
Mailing Address - Fax:941-794-8017
Practice Address - Street 1:1410 59TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-4607
Practice Address - Country:US
Practice Address - Phone:941-792-1477
Practice Address - Fax:941-794-8017
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-12
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0016360208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5082014OtherAETNA
FL340003525OtherRAILROAD MEDICARE
D54792Medicare UPIN
FL99145Medicare PIN