Provider Demographics
NPI:1962484949
Name:POLES, JACK NATHAN (MD)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:NATHAN
Last Name:POLES
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2500 W UTOPIA RD
Mailing Address - Street 2:STE. 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-4171
Mailing Address - Country:US
Mailing Address - Phone:602-214-6148
Mailing Address - Fax:602-214-6149
Practice Address - Street 1:9100 N 2ND ST
Practice Address - Street 2:SUITE 121
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2446
Practice Address - Country:US
Practice Address - Phone:602-997-7331
Practice Address - Fax:602-870-4512
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2013-09-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZAP6412085207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ41884OtherBOARD CERT #
AZD37458Medicare UPIN
AZ41884OtherBOARD CERT #