Provider Demographics
NPI:1578844775
Name:POLANCO CASTILLO, GEORGINA (MD)
Entity Type:Individual
Prefix:
First Name:GEORGINA
Middle Name:
Last Name:POLANCO CASTILLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8340 BANDFORD WAY
Mailing Address - Street 2:STE 1
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-2755
Mailing Address - Country:US
Mailing Address - Phone:919-845-3332
Mailing Address - Fax:
Practice Address - Street 1:8340 BANDFORD WAY STE 1
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-2755
Practice Address - Country:US
Practice Address - Phone:919-845-3332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-31
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2015-0855207RE0101X
NC2020-0766207RE0101X
MI4301099326207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM05332044Medicaid
NC05332044Medicaid