Provider Demographics
NPI:1770584252
Name:POLLAN, SUSAN B (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:B
Last Name:POLLAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6349 BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-2707
Mailing Address - Country:US
Mailing Address - Phone:904-721-1919
Mailing Address - Fax:904-721-1914
Practice Address - Street 1:6349 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-2707
Practice Address - Country:US
Practice Address - Phone:904-721-1919
Practice Address - Fax:904-721-1914
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA75361207L00000X
MAME87957208VP0000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3103081Medicaid
FLBP0135079OtherCONTROLLED SUBSTANCE REGISTRATION CERTIFICATE
MAJ12535Medicare ID - Type Unspecified