Provider Demographics
NPI:1659402964
Name:POLLES, MARK BENEDICT (NP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:BENEDICT
Last Name:POLLES
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPT 1265
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80256-0001
Mailing Address - Country:US
Mailing Address - Phone:866-898-7138
Mailing Address - Fax:
Practice Address - Street 1:5637 MARINE PKWY
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-4316
Practice Address - Country:US
Practice Address - Phone:727-848-1733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2017-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95004120363L00000X
FLARNP2026672363L00000X
CORN-165625363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN255456900Medicaid
MN995N5POOtherBCBSM
CO59031735Medicaid
MN8HD740Medicare ID - Type Unspecified
COC0304331Medicare PIN
CO59031735Medicaid