=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386707636
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAYMOND ISRAEL POLIAKIN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2006
-----------------------------------------------------
Last Update Date | 03/07/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 227 W JANSS RD STE 300
-----------------------------------------------------
City | THOUSAND OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91360-1885
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-497-8820
-----------------------------------------------------
Fax | 805-496-2072
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 227 WEST JANSS ROAD SUITE 300
-----------------------------------------------------
City | THOUSAND OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-497-8820
-----------------------------------------------------
Fax | 805-496-2072
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | G42576
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------