Provider Demographics
NPI:1376562090
Name:POLATNICK, MARK JASON (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JASON
Last Name:POLATNICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:41 N MAIN ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-1972
Mailing Address - Country:US
Mailing Address - Phone:860-313-0448
Mailing Address - Fax:860-313-1464
Practice Address - Street 1:41 N MAIN ST
Practice Address - Street 2:SUITE 300
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-1972
Practice Address - Country:US
Practice Address - Phone:860-313-0448
Practice Address - Fax:860-313-1464
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT038683207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010038683CT02OtherANTHEM BLUE SHIELD
3V0199OtherHEALTHNET
CT1376562090Medicaid
3V0199OtherHEALTHNET
CTH13909Medicare UPIN