Healthcare Provider Details

I. General information

NPI: 1871752956
Provider Name (Legal Business Name): TRAVIS POLLEMA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9434 MEDICAL CENTER DR FL 1
LA JOLLA CA
92037-1337
US

IV. Provider business mailing address

PO BOX 232410
SAN DIEGO CA
92193-2410
US

V. Phone/Fax

Practice location:
  • Phone: 858-657-7777
  • Fax: 858-657-5058
Mailing address:
  • Phone: 858-249-6749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number20A12742
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number20A12742
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: