Healthcare Provider Details

I. General information

NPI: 1073760815
Provider Name (Legal Business Name): AMY CATON POLVERINI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2008
Last Update Date: 06/28/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 FAIR OAKS AVE
SOUTH PASADENA CA
91030-1814
US

IV. Provider business mailing address

PO BOX 512185
LOS ANGELES CA
90051-0185
US

V. Phone/Fax

Practice location:
  • Phone: 626-396-2900
  • Fax:
Mailing address:
  • Phone: 626-775-3514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberA111253
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA111253
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: