Provider Demographics
NPI:1508892407
Name:POLAK, JOHN H (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:H
Last Name:POLAK
Suffix:
Gender:M
Credentials:DO
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 532780
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-2780
Mailing Address - Country:US
Mailing Address - Phone:904-805-1300
Mailing Address - Fax:904-805-1302
Practice Address - Street 1:1350 WALTON WAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2612
Practice Address - Country:US
Practice Address - Phone:904-805-1300
Practice Address - Fax:904-805-1302
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA31100207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000403807CMedicaid
GA623872OtherBLUE CROSS
SCG31100Medicaid
SCG31100OtherSOUTH CAROLINA MEDICAID
GAE45745Medicare UPIN
GA93BBHTKMedicare PIN