MEDICARE: DR. JAMES POLKABLA O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	649	AZ

General Provider Information

NPI Number	:	1467440818
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMES POLKABLA O.D.

Provider Business Mailing Address
First Line	:	220 N MCKEMY AVE
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85226-2654
Country	:	US
Telephone Number	:	480-961-1865
Fax Number	:	480-961-4605

Provider Business Practice Location Address
First Line	:	9524 W CAMELBACK RD
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85305-3104
Country	:	US
Telephone Number	:	623-872-8822
Fax Number	:	623-772-8216

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2005
Last Update Date	:	05/07/2014

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