Healthcare Provider Details

I. General information

NPI: 1174654511
Provider Name (Legal Business Name): JAMES ALAN POLO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 04/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 SOUTH L STREET
TACOMA WA
98405
US

IV. Provider business mailing address

311 SOUTH L STREET
TACOMA WA
98405
US

V. Phone/Fax

Practice location:
  • Phone: 253-403-1420
  • Fax:
Mailing address:
  • Phone: 253-403-1420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD60218274
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD60218274
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD60218274
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35068
License Number StateCO
# 5
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number35068
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: