Provider Demographics
NPI:1578536306
Name:POLTEROCK, JERROLD (MD)
Entity Type:Individual
Prefix:
First Name:JERROLD
Middle Name:
Last Name:POLTEROCK
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 1:250 S OAK AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:OAKDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95361-3572
Mailing Address - Country:US
Mailing Address - Phone:209-845-0100
Mailing Address - Fax:209-845-0130
Practice Address - Street 1:250 S OAK AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:OAKDALE
Practice Address - State:CA
Practice Address - Zip Code:95361-3572
Practice Address - Country:US
Practice Address - Phone:209-845-0100
Practice Address - Fax:209-845-0130
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG16347207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ07922ZOtherBLUE SHIELD
CA00G163471Medicaid
CAZZZ07922ZOtherBLUE SHIELD
G16347Medicare ID - Type Unspecified