Provider Demographics
NPI:1891719233
Name:POLSTON, GREGORY R (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:R
Last Name:POLSTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9500 GILMAN DR
Mailing Address - Street 2:UCSD DEPARTMENT OF ANESTHESIOLOGY
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92093-0801
Mailing Address - Country:US
Mailing Address - Phone:619-543-3162
Mailing Address - Fax:907-743-8284
Practice Address - Street 1:3600 GILMAN DR
Practice Address - Street 2:UCSD DEPARTMENT OF ANESTHESIOLOGY
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92093-0801
Practice Address - Country:US
Practice Address - Phone:619-543-3162
Practice Address - Fax:907-743-8284
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AKAK4664207LP2900X
CAG70548207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD4216Medicaid
AKMD4216Medicaid
AK151725Medicare ID - Type Unspecified