Provider Demographics
NPI:1942283676
Name:POLSTER, DARRELL MARTIN (MD)
Entity Type:Individual
Prefix:
First Name:DARRELL
Middle Name:MARTIN
Last Name:POLSTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8905 SW NIMBUS AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-7136
Mailing Address - Country:US
Mailing Address - Phone:503-372-2740
Mailing Address - Fax:503-372-2754
Practice Address - Street 1:335 SE 8TH AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4246
Practice Address - Country:US
Practice Address - Phone:503-681-1270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-28
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35084131P207L00000X
ORMD171659207L00000X
CAG88700207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2486493Medicaid
3494801OtherAETNA
000000327106OtherANTHEM BLUE SHIELD
KY64079379Medicaid
IN200483990Medicaid
5781475OtherAETNA
P00125052Medicare PIN
KY64079379Medicaid
P00125052Medicare PIN