Provider Demographics
NPI:1164409231
Name:POLUHA, WOJCIECH (MD)
Entity Type:Individual
Prefix:
First Name:WOJCIECH
Middle Name:
Last Name:POLUHA
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 1:107 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2401
Mailing Address - Country:US
Mailing Address - Phone:508-799-9000
Mailing Address - Fax:508-453-3107
Practice Address - Street 1:107 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2401
Practice Address - Country:US
Practice Address - Phone:508-799-9000
Practice Address - Fax:508-453-3107
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMP0462933A207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0176303Medicaid
MAH54370Medicare UPIN
MA0176303Medicaid