Healthcare Provider Details

I. General information

NPI: 1306844022
Provider Name (Legal Business Name): RUBEN POLLAK D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 02/15/2017
Certification Date:
Deactivation Date: 03/15/2006
Reactivation Date: 05/10/2006

III. Provider practice location address

1369 N 10TH AVE
STAYTON OR
97383-2037
US

IV. Provider business mailing address

1369 N 10TH AVE
STAYTON OR
97383
US

V. Phone/Fax

Practice location:
  • Phone: 503-769-7960
  • Fax: 503-769-9860
Mailing address:
  • Phone: 503-769-7960
  • Fax: 503-769-2172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberDP00368
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: