Provider Demographics
NPI:1538138631
Name:POLANCO, TRACY L (MD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:L
Last Name:POLANCO
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 1:769 MEDICAL CENTER CT
Mailing Address - Street 2:SUITE 303
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-6602
Mailing Address - Country:US
Mailing Address - Phone:619-591-9001
Mailing Address - Fax:619-591-9211
Practice Address - Street 1:769 MEDICAL CENTER CT
Practice Address - Street 2:SUITE 303
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-6602
Practice Address - Country:US
Practice Address - Phone:619-591-9001
Practice Address - Fax:619-591-9211
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA80610207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA80610AMedicare ID - Type Unspecified
CAI18590Medicare UPIN
CA00A806100Medicaid