Healthcare Provider Details

I. General information

NPI: 1720414014
Provider Name (Legal Business Name): WILLIAM HOWARD POLONSKY PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2013
Last Update Date: 09/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5405 OBERLIN DR SUITE 100
SAN DIEGO CA
92121-1700
US

IV. Provider business mailing address

PO BOX 2148
DEL MAR CA
92014-1448
US

V. Phone/Fax

Practice location:
  • Phone: 760-525-5256
  • Fax: 760-942-5780
Mailing address:
  • Phone: 760-525-5256
  • Fax: 760-942-5780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License NumberPSY13764
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: