Provider Demographics
NPI:1265420921
Name:POLAKOFF, STEPHEN MARK (OD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:MARK
Last Name:POLAKOFF
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 S CAMP MEADE RD
Mailing Address - Street 2:
Mailing Address - City:LINTHICUM
Mailing Address - State:MD
Mailing Address - Zip Code:21090-2701
Mailing Address - Country:US
Mailing Address - Phone:410-859-3111
Mailing Address - Fax:
Practice Address - Street 1:413 S CAMP MEADE RD
Practice Address - Street 2:
Practice Address - City:LINTHICUM
Practice Address - State:MD
Practice Address - Zip Code:21090-2701
Practice Address - Country:US
Practice Address - Phone:410-859-3111
Practice Address - Fax:410-859-8222
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-07
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDMD0668TA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T78775Medicare UPIN
Z465Medicare PIN