Healthcare Provider Details

I. General information

NPI: 1427144583
Provider Name (Legal Business Name): PAVEL POLEHNA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 04/30/2020
Certification Date: 04/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 NE 87TH AVE
VANCOUVER WA
98664-1913
US

IV. Provider business mailing address

700 NE 87TH AVE
VANCOUVER WA
98664-1913
US

V. Phone/Fax

Practice location:
  • Phone: 360-254-1240
  • Fax: 360-397-3128
Mailing address:
  • Phone: 360-254-1240
  • Fax: 360-397-3128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA97249
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD162124
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number41935
License Number StateMT
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2015-0793
License Number StateNM
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number10464A
License Number StateWY
# 6
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number16301
License Number StateNV
# 7
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD-18503
License Number StateHI
# 8
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0056351
License Number StateCO
# 9
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-13199
License Number StateID
# 10
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number51068
License Number StateAZ
# 11
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number113948
License Number StateAK
# 12
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00047152
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: