Provider Demographics
NPI:1467497479
Name:POLLACK, CHARLES V JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:V
Last Name:POLLACK
Suffix:JR
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:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30077-0308
Mailing Address - Country:US
Mailing Address - Phone:610-329-2986
Mailing Address - Fax:888-959-8345
Practice Address - Street 1:1120 WILDE RUN CT
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-7163
Practice Address - Country:US
Practice Address - Phone:610-329-2986
Practice Address - Fax:888-959-8345
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-17
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD072992L207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8435502Medicaid
PA0018330190001Medicaid
NJ8435502Medicaid
E15076Medicare UPIN