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NPI Code Detail

MEDICARE: MR. JACK NATHAN POLES M.D.

MEDICARE: MR. JACK NATHAN POLES M.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207R00000XInternal Medicine PhysicianAP6412085AZ

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
141884OTHERAZBOARD CERT #

General Provider Information

NPI Number : 1962484949
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. JACK NATHAN POLES M.D.
Provider Business Mailing Address
First Line : 2500 W UTOPIA RD
Second Line : STE. 100
City : PHOENIX
State : AZ
Zip : 85027-4171
Country : US
Telephone Number : 602-214-6148
Fax Number : 602-214-6149
Provider Business Practice Location Address
First Line : 9100 N 2ND ST
Second Line : SUITE 121
City : PHOENIX
State : AZ
Zip : 85020-2446
Country : US
Telephone Number : 602-997-7331
Fax Number : 602-870-4512
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/16/2005
Last Update Date : 09/24/2013

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