Healthcare Provider Details

I. General information

NPI: 1700825205
Provider Name (Legal Business Name): GARY POLSFUSS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 07/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 E 4TH ST EMERGENCY DEPARTMENT
NATIONAL CITY CA
91950-2026
US

IV. Provider business mailing address

111 N SEPULVEDA BLVD SUITE 210
MANHATTAN BEACH CA
90266-6861
US

V. Phone/Fax

Practice location:
  • Phone: 619-470-4321
  • Fax:
Mailing address:
  • Phone: 310-379-2134
  • Fax: 310-379-4856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA066536
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: