Provider Demographics
NPI:1902830557
Name:POLOFSKY, ROBERT
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:POLOFSKY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 BROADWAY STE 207
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701
Mailing Address - Country:US
Mailing Address - Phone:631-598-0009
Mailing Address - Fax:
Practice Address - Street 1:221 BROADWAY SUITE 207
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701
Practice Address - Country:US
Practice Address - Phone:631-598-0009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY168859207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY080142404OtherMEDICARE RAIL ROAD
NYRP097F4710OtherEMPIRE BLUE CROSS BLUE SHIELD
NY01558938Medicaid
NY01558938Medicaid
NY080142404OtherMEDICARE RAIL ROAD
NYRP097F4710OtherEMPIRE BLUE CROSS BLUE SHIELD