Provider Demographics
NPI:1518924885
Name:POLSE, SANFORD LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:SANFORD
Middle Name:LEE
Last Name:POLSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2625 W ALAMEDA AVE
Mailing Address - Street 2:306
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505
Mailing Address - Country:US
Mailing Address - Phone:818-843-4604
Mailing Address - Fax:818-843-4698
Practice Address - Street 1:2625 W ALAMEDA AVE
Practice Address - Street 2:306
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505
Practice Address - Country:US
Practice Address - Phone:818-843-4604
Practice Address - Fax:818-843-4698
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-28
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA21102208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A211020Medicaid
A22458Medicare UPIN
CA00A211020Medicaid