Provider Demographics
NPI:1710372628
Name:POLJAK, DIJANA (MD)
Entity Type:Individual
Prefix:DR
First Name:DIJANA
Middle Name:
Last Name:POLJAK
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 1:4901 FOREST PARK AVE
Mailing Address - Street 2:MAILSTOP 8064-37-1005
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-1495
Mailing Address - Country:US
Mailing Address - Phone:314-273-4724
Mailing Address - Fax:314-362-0049
Practice Address - Street 1:4901 FOREST PARK AVE
Practice Address - Street 2:STE 710
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-1495
Practice Address - Country:US
Practice Address - Phone:314-273-4724
Practice Address - Fax:314-362-0049
Is Sole Proprietor?:No
Enumeration Date:2015-03-30
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019005178207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200070770Medicaid