Provider Demographics
NPI:1114177938
Name:JOSE F POLANCO MD PA
Entity Type:Organization
Organization Name:JOSE F POLANCO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:F
Authorized Official - Last Name:POLANCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-708-3358
Mailing Address - Street 1:311 3RD AVE E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-1014
Mailing Address - Country:US
Mailing Address - Phone:941-708-3358
Mailing Address - Fax:941-749-1046
Practice Address - Street 1:311 3RD AVE E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-1014
Practice Address - Country:US
Practice Address - Phone:941-708-3358
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-29
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME73836207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003131900Medicaid
FL419213AMedicare PIN