Provider Demographics
NPI:1467440818
Name:POLKABLA, JAMES (OD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:
Last Name:POLKABLA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 N MCKEMY AVE
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-2654
Mailing Address - Country:US
Mailing Address - Phone:480-961-1865
Mailing Address - Fax:480-961-4605
Practice Address - Street 1:9524 W CAMELBACK RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85305-3104
Practice Address - Country:US
Practice Address - Phone:623-872-8822
Practice Address - Fax:623-772-8216
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ649152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ164149Medicare PIN
AZZ162076Medicare PIN
AZZ162077Medicare PIN
AZZ164148Medicare PIN
AZZ162075Medicare PIN
AZZ162079Medicare PIN
AZZ164146Medicare PIN
AZU75213Medicare UPIN
AZZ65062Medicare PIN
AZZ164144Medicare PIN
AZZ164147Medicare PIN
AZZ162074Medicare PIN
AZZ164145Medicare PIN
AZZ162078Medicare PIN