Provider Demographics
NPI:1528178936
Name:PODOLSKY, ANATOL (MD)
Entity Type:Individual
Prefix:
First Name:ANATOL
Middle Name:
Last Name:PODOLSKY
Suffix:
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 1:4627 SURREY DR
Mailing Address - Street 2:
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-2725
Mailing Address - Country:US
Mailing Address - Phone:949-644-4897
Mailing Address - Fax:
Practice Address - Street 1:18035 BROOKHUST STREET SUITE 1200
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-9270
Practice Address - Country:US
Practice Address - Phone:949-644-6882
Practice Address - Fax:949-644-2377
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG71630174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG71630Medicare PIN
CAE87074Medicare UPIN