Provider Demographics
NPI:1710402219
Name:STEPHEN POLAKOFF
Entity Type:Organization
Organization Name:STEPHEN POLAKOFF
Other - Org Name:VISION SOURCE OF LINTHICUM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OM
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-859-3111
Mailing Address - Street 1:413 S CAMP MEADE RD
Mailing Address - Street 2:
Mailing Address - City:LINTHICUM
Mailing Address - State:MD
Mailing Address - Zip Code:21090-2701
Mailing Address - Country:US
Mailing Address - Phone:410-859-3111
Mailing Address - Fax:
Practice Address - Street 1:413 S CAMP MEADE RD
Practice Address - Street 2:
Practice Address - City:LINTHICUM
Practice Address - State:MD
Practice Address - Zip Code:21090-2701
Practice Address - Country:US
Practice Address - Phone:410-859-3111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA0668152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD8019088Medicaid