Provider Demographics
NPI:1659324465
Name:POLACK, DONOVAN C (MD)
Entity Type:Individual
Prefix:DR
First Name:DONOVAN
Middle Name:C
Last Name:POLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11155 DUNN RD STE 211N
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-6166
Mailing Address - Country:US
Mailing Address - Phone:314-741-1600
Mailing Address - Fax:314-741-1677
Practice Address - Street 1:11155 DUNN RD
Practice Address - Street 2:SUITE 211N
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6150
Practice Address - Country:US
Practice Address - Phone:314-741-1600
Practice Address - Fax:314-741-1677
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5H69207RN0300X, 174400000X
IL036-072078174400000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202546321Medicaid
IL036072078Medicaid
ILK28494Medicare PIN
MOA12440Medicare UPIN
MO023124377Medicare ID - Type UnspecifiedMO MEDICARE INDIVIDUAL#