Healthcare Provider Details

I. General information

NPI: 1841812716
Provider Name (Legal Business Name): DR. GARY D. POLAN, OD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2020
Last Update Date: 05/13/2020
Certification Date: 05/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

970 MONUMENT ST STE 102
PACIFIC PALISADES CA
90272-3860
US

IV. Provider business mailing address

970 MONUMENT ST STE 102
PACIFIC PALISADES CA
90272-3860
US

V. Phone/Fax

Practice location:
  • Phone: 310-459-0055
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. GARY POLAN
Title or Position: OPTOMETRIST
Credential:
Phone: 310-459-0055