Basic Information
| Provider Information | |||||||||
| NPI: | 1356315303 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLAKOFF | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | BARRY | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4850 W OAKLAND PARK BLVD | ||||||||
| Address2: | SUITE 143 | ||||||||
| City: | LAUDERDALE LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333137260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9546769980 | ||||||||
| FaxNumber: | 9546765288 | ||||||||
| Practice Location | |||||||||
| Address1: | 4850 W OAKLAND PARK BLVD | ||||||||
| Address2: | SUITE 143 | ||||||||
| City: | LAUDERDALE LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333137260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9546769980 | ||||||||
| FaxNumber: | 9546765288 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 09/02/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | ME0046546 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 37534900 | 05 | FL | MEDICAID |