Provider Demographics
NPI:1467424986
Name:POLLACK, LAWRENCE A (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:A
Last Name:POLLACK
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 1:475 S DOBSON RD
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-5605
Mailing Address - Country:US
Mailing Address - Phone:480-728-3753
Mailing Address - Fax:480-728-3753
Practice Address - Street 1:475 S DOBSON RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5605
Practice Address - Country:US
Practice Address - Phone:480-728-3753
Practice Address - Fax:480-728-3753
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT6007207P00000X
AZ25105207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000641OtherBCBC ER GROUP
MT0034714Medicaid
000000641OtherBCBC ER GROUP
MT0034714Medicaid
930002225Medicare ID - Type UnspecifiedMEDICARE RAILROAD