Provider Demographics
NPI:1790749208
Name:POLAK, CLARA LUCY (MD)
Entity Type:Individual
Prefix:
First Name:CLARA
Middle Name:LUCY
Last Name:POLAK
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 1:480 4TH AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-4410
Mailing Address - Country:US
Mailing Address - Phone:619-427-3361
Mailing Address - Fax:619-427-6821
Practice Address - Street 1:480 4TH AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-4410
Practice Address - Country:US
Practice Address - Phone:619-427-3361
Practice Address - Fax:619-427-6821
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66649207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0083510Medicaid
CAW14392Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
CAG81625Medicare UPIN