Provider Demographics
NPI:1306844022
Name:POLLAK, RUBEN (DPM)
Entity Type:Individual
Prefix:DR
First Name:RUBEN
Middle Name:
Last Name:POLLAK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1369 N 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:STAYTON
Mailing Address - State:OR
Mailing Address - Zip Code:97383
Mailing Address - Country:US
Mailing Address - Phone:503-769-7960
Mailing Address - Fax:503-769-2172
Practice Address - Street 1:1369 N 10TH AVE
Practice Address - Street 2:
Practice Address - City:STAYTON
Practice Address - State:OR
Practice Address - Zip Code:97383-2037
Practice Address - Country:US
Practice Address - Phone:503-769-7960
Practice Address - Fax:503-769-9860
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2017-02-15
Deactivation Date:2006-03-15
Deactivation Code:
Reactivation Date:2006-05-10
Provider Licenses
StateLicense IDTaxonomies
ORDP00368213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR271049Medicaid
CA4020070001OtherCIGNA MEDICARE DMERC
CA4020070001OtherCIGNA MEDICARE DMERC
OR6173880001Medicare NSC
U77638Medicare UPIN