Healthcare Provider Details

I. General information

NPI: 1710402219
Provider Name (Legal Business Name): STEPHEN POLAKOFF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 S CAMP MEADE RD
LINTHICUM MD
21090-2701
US

IV. Provider business mailing address

413 S CAMP MEADE RD
LINTHICUM MD
21090-2701
US

V. Phone/Fax

Practice location:
  • Phone: 410-859-3111
  • Fax:
Mailing address:
  • Phone: 410-859-3111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA0668
License Number StateMD

VIII. Authorized Official

Name: CHRISTY KLEIN
Title or Position: OM
Credential:
Phone: 410-859-3111