Provider Demographics
NPI:1225255995
Name:POLANCO, SAMUEL (DO)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:
Last Name:POLANCO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 ESSEX ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01840
Mailing Address - Country:US
Mailing Address - Phone:978-689-4402
Mailing Address - Fax:978-688-5890
Practice Address - Street 1:327 ESSEX ST
Practice Address - Street 2:VISION OPTICAL
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01840
Practice Address - Country:US
Practice Address - Phone:978-689-4402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4228156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1526014Medicaid