Provider Demographics
NPI:1598042178
Name:SHIVANAND R POLE MD INC
Entity Type:Organization
Organization Name:SHIVANAND R POLE MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHIVANAND
Authorized Official - Middle Name:RAO
Authorized Official - Last Name:POLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-246-6061
Mailing Address - Street 1:3851 KATELLA AVENUE
Mailing Address - Street 2:305
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3915
Mailing Address - Country:US
Mailing Address - Phone:562-246-6061
Mailing Address - Fax:562-430-8600
Practice Address - Street 1:3851 KATELLA AVENUE
Practice Address - Street 2:305
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3915
Practice Address - Country:US
Practice Address - Phone:562-246-6061
Practice Address - Fax:562-430-8600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-09
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA101547207R00000X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty