Provider Demographics
NPI:1184664757
Name:POLANCO MARTINEZ, MANUEL R (MD)
Entity Type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:R
Last Name:POLANCO MARTINEZ
Suffix:
Gender:M
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:PO BOX 144035
Mailing Address - Street 2:PMB 453
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00614-4035
Mailing Address - Country:US
Mailing Address - Phone:787-879-3352
Mailing Address - Fax:787-880-3016
Practice Address - Street 1:14 CALLE GONZALO MARIN
Practice Address - Street 2:
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00612-4703
Practice Address - Country:US
Practice Address - Phone:787-879-3352
Practice Address - Fax:787-880-3016
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR8462207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR29879Medicaid
PR0029879Medicare ID - Type Unspecified
PR29879Medicaid