Provider Demographics
NPI:1609649136
Name:POLANCO, MITZANIA (DO)
Entity Type:Individual
Prefix:
First Name:MITZANIA
Middle Name:
Last Name:POLANCO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6745 NW 169TH ST APT G
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-4230
Mailing Address - Country:US
Mailing Address - Phone:786-564-2439
Mailing Address - Fax:
Practice Address - Street 1:15470 NW 77TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33016-5823
Practice Address - Country:US
Practice Address - Phone:786-564-2439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO6785156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician