Provider Demographics
NPI:1457438624
Name:POLOWAY, MARK D (PHD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:POLOWAY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4006 ISLE DR
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-3615
Mailing Address - Country:US
Mailing Address - Phone:760-612-5490
Mailing Address - Fax:760-859-3002
Practice Address - Street 1:2181 EL CAMINO REAL
Practice Address - Street 2:SUITE 205
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-6222
Practice Address - Country:US
Practice Address - Phone:760-612-5490
Practice Address - Fax:760-859-3002
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8883103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPK00088830Medicaid
CACP8883Medicare ID - Type Unspecified