Provider Demographics
NPI:1316033517
Name:EJ POLITOSKE MD INC
Entity Type:Organization
Organization Name:EJ POLITOSKE MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:POLITOSKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-734-9930
Mailing Address - Street 1:341 MAGNOLIA AVENUE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879
Mailing Address - Country:US
Mailing Address - Phone:951-734-9930
Mailing Address - Fax:951-734-9692
Practice Address - Street 1:341 MAGNOLIA AVENUE
Practice Address - Street 2:SUITE 207
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879
Practice Address - Country:US
Practice Address - Phone:951-734-9930
Practice Address - Fax:951-734-9692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41806207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A418060Medicaid
CA00A418060Medicaid
CAZZZ32564ZMedicare ID - Type Unspecified