Provider Demographics
NPI:1114941051
Name:POLK, ERNEST KEITH (MD)
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:KEITH
Last Name:POLK
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 1:900 N ALMANSOR ST
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-1127
Mailing Address - Country:US
Mailing Address - Phone:626-289-7419
Mailing Address - Fax:626-289-7419
Practice Address - Street 1:100 W CALIFORNIA BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3010
Practice Address - Country:US
Practice Address - Phone:626-397-5000
Practice Address - Fax:626-397-2912
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC39853207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C398530OtherBLUE SHIELD
CA00C398530Medicaid
CA00C398530Medicaid
D71780Medicare UPIN