Provider Demographics
NPI:1629048350
Name:POLAN, RUTH L (MD)
Entity Type:Individual
Prefix:DR
First Name:RUTH
Middle Name:L
Last Name:POLAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2190 LYNN RD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-1980
Mailing Address - Country:US
Mailing Address - Phone:805-495-8050
Mailing Address - Fax:805-496-2160
Practice Address - Street 1:227 W JANSS RD
Practice Address - Street 2:SUITE 150
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-1848
Practice Address - Country:US
Practice Address - Phone:805-496-7755
Practice Address - Fax:805-379-3913
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG440762085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G447060Medicaid
CA00G447060Medicaid
CAAT377ZMedicare PIN
A92464Medicare UPIN
WG44076AMedicare PIN