Provider Demographics
NPI:1205890365
Name:POLES, GWENDOLYN A (DO)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:A
Last Name:POLES
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1677
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2501 N 3RD ST
Practice Address - Street 2:2ND FLOOR LANDIS BLDG
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17110-1904
Practice Address - Country:US
Practice Address - Phone:717-782-2100
Practice Address - Fax:717-782-2121
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2025-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS006744L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007444090003Medicaid
PA630052OtherMEDICARE NUMBER
PA630052Medicare PIN