Healthcare Provider Details

I. General information

NPI: 1467415281
Provider Name (Legal Business Name): JAY HOWARD POLOKOFF M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 04/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 PHILIP BLVD, SUITE 130 KAISER PERMANENTE LAWRENCEVILLE MEDICAL CENTER
LAWRENCEVILLE GA
30046
US

IV. Provider business mailing address

3495 PIEDMONT ROAD, NE NINE PIEDMONT CENTER
ATLANTA GA
30305
US

V. Phone/Fax

Practice location:
  • Phone: 678-985-5006
  • Fax: 770-449-9319
Mailing address:
  • Phone: 404-364-7070
  • Fax: 770-449-9319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number026051
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: