Provider Demographics
NPI:1700825205
Name:POLSFUSS, GARY (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:POLSFUSS
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 1:111 N SEPULVEDA BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-6861
Mailing Address - Country:US
Mailing Address - Phone:310-379-2134
Mailing Address - Fax:310-379-4856
Practice Address - Street 1:2400 E 4TH ST
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-2026
Practice Address - Country:US
Practice Address - Phone:619-470-4321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA066536207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH20741Medicare UPIN
CAWA66536AMedicare PIN