Provider Demographics
NPI:1659750560
Name:POLAK, JONATHAN (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:POLAK
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 1:17909 SOLEDAD CANYON RD # 100
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91387-3210
Mailing Address - Country:US
Mailing Address - Phone:661-367-3500
Mailing Address - Fax:661-367-3539
Practice Address - Street 1:17909 SOLEDAD CANYON RD # 100
Practice Address - Street 2:
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91387-3210
Practice Address - Country:US
Practice Address - Phone:661-367-3500
Practice Address - Fax:661-367-3539
Is Sole Proprietor?:No
Enumeration Date:2015-05-26
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH19473207R00000X
CAC194706207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107650300Medicaid