Healthcare Provider Details

I. General information

NPI: 1841604436
Provider Name (Legal Business Name): MELISSA POLIBOY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MELISSA BLANKENBECKLER

II. Dates (important events)

Enumeration Date: 06/11/2014
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 W SUNSET BLVD
LOS ANGELES CA
90027-6062
US

IV. Provider business mailing address

320 LENNON LN
WALNUT CREEK CA
94598-2419
US

V. Phone/Fax

Practice location:
  • Phone: 323-361-2110
  • Fax:
Mailing address:
  • Phone: 925-906-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA124194
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: