Provider Demographics
NPI:1871534636
Name:POHOST, GERALD M (MD)
Entity type:Individual
Prefix:DR
First Name:GERALD
Middle Name:M
Last Name:POHOST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2200 NORTH MAYFAIR ROAD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-2252
Mailing Address - Country:US
Mailing Address - Phone:414-258-9511
Mailing Address - Fax:414-607-3946
Practice Address - Street 1:1505 WILSON TERRACE
Practice Address - Street 2:SUITE 150
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:61206-4007
Practice Address - Country:US
Practice Address - Phone:818-409-3501
Practice Address - Fax:818-956-7680
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2012-05-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG86422207RC0000X
CAG84622207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ68624YOtherBLUE SHIELD
CA1871534636OtherBLUE CROSS
CAP01016324OtherRR MEDICARE
CAZZZ68624YOtherBLUE SHIELD
CAWG86422AMedicare PIN