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General NPI Number Information
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NPI Number | 1457438624
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Entity Type | Individual
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Provider Name | MARK D POLOWAY PH.D.
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Gender | Male
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Dates
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Enumeration Date | 11/01/2006
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Last Update Date | 12/28/2016
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Provider Practice Location Address
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Address Line | 2181 EL CAMINO REAL SUITE 205
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City | OCEANSIDE
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State | CA
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Zip | 92054-6222
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Country | US
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Telephone | 760-612-5490
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Fax | 760-859-3002
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Provider Business Mailing Address
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Address Line | 4006 ISLE DR
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City | CARLSBAD
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State | CA
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Zip | 92008-3615
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Country | US
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Telephone | 760-612-5490
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Fax | 760-859-3002
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY8883
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License Number State | CA
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