Provider Demographics
NPI:1487653523
Name:POLLACK, ROBERT B (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:B
Last Name:POLLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4510 EXECUTIVE DR.
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-3022
Mailing Address - Country:US
Mailing Address - Phone:858-457-8686
Mailing Address - Fax:858-450-7690
Practice Address - Street 1:4510 EXECUTIVE DR.
Practice Address - Street 2:SUITE 105
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3022
Practice Address - Country:US
Practice Address - Phone:858-457-8686
Practice Address - Fax:858-450-7690
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG0675512086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G675510Medicaid
CA00G675510Medicaid
CAF11845Medicare UPIN