Provider Demographics
NPI:1356473847
Name:POLANSHEK, MARK MUMFORD (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:MUMFORD
Last Name:POLANSHEK
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 1:4707 BUCKINGHAM CT
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-4261
Mailing Address - Country:US
Mailing Address - Phone:804-796-2300
Mailing Address - Fax:804-751-4815
Practice Address - Street 1:4707 BUCKINGHAM CT
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831-4261
Practice Address - Country:US
Practice Address - Phone:804-796-2300
Practice Address - Fax:804-751-4815
Is Sole Proprietor?:No
Enumeration Date:2007-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010411672080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6702481Medicaid
VAF19718Medicare UPIN