Provider Demographics
NPI:1467415281
Name:POLOKOFF, JAY HOWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:HOWARD
Last Name:POLOKOFF
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Gender:M
Credentials:MD
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Mailing Address - Street 1:3495 PIEDMONT ROAD, NE
Mailing Address - Street 2:NINE PIEDMONT CENTER
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305
Mailing Address - Country:US
Mailing Address - Phone:404-364-7070
Mailing Address - Fax:770-449-9319
Practice Address - Street 1:455 PHILIP BLVD, SUITE 130
Practice Address - Street 2:KAISER PERMANENTE LAWRENCEVILLE MEDICAL CENTER
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046
Practice Address - Country:US
Practice Address - Phone:678-985-5006
Practice Address - Fax:770-449-9319
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2012-04-26
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Provider Licenses
StateLicense IDTaxonomies
GA026051208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000338511BMedicaid