Basic Information
| Provider Information | |||||||||
| NPI: | 1710372628 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POLJAK | ||||||||
| FirstName: | DIJANA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4901 FOREST PARK AVE | ||||||||
| Address2: | MAILSTOP 8064-37-1005 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631081495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142734724 | ||||||||
| FaxNumber: | 3143620049 | ||||||||
| Practice Location | |||||||||
| Address1: | 4901 FOREST PARK AVE | ||||||||
| Address2: | STE 710 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631081495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142734724 | ||||||||
| FaxNumber: | 3143620049 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2015 | ||||||||
| LastUpdateDate: | 08/01/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 2019005178 | MO | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 200070770 | 05 | MO | MEDICAID |