Provider Demographics
NPI:1265490056
Name:POLLEY, GORDON M (M D)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:M
Last Name:POLLEY
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11945 SAN JOSE BLVD
Mailing Address - Street 2:BLDG 300
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-1627
Mailing Address - Country:US
Mailing Address - Phone:904-396-1725
Mailing Address - Fax:904-399-1717
Practice Address - Street 1:836 PRUDENTIAL DR
Practice Address - Street 2:SUITE 1001
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8334
Practice Address - Country:US
Practice Address - Phone:904-398-0033
Practice Address - Fax:904-398-6774
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME51872208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL274941600Medicaid
1265866OtherCIGNA
4664231OtherAETNA
100414OtherAVMED
FL020040220OtherRAILROAD MEDICARE
12615OtherBCBS FL
12615OtherBCBS FL
FL020040220OtherRAILROAD MEDICARE