Healthcare Provider Details

I. General information

NPI: 1467258772
Provider Name (Legal Business Name): CLARA LUCKY POLAK MD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2025
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 W 35TH ST STE 101
NATIONAL CITY CA
91950-7926
US

IV. Provider business mailing address

22 W 35TH ST STE 101
NATIONAL CITY CA
91950-7926
US

V. Phone/Fax

Practice location:
  • Phone: 619-427-3361
  • Fax:
Mailing address:
  • Phone: 619-427-3361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State

VIII. Authorized Official

Name: KATHYN MARIE MORA
Title or Position: ADMINISTRATOR ASSISTANT
Credential:
Phone: 619-827-0572