Provider Demographics
NPI:1629357033
Name:POLANCO, MARIO (DO)
Entity Type:Individual
Prefix:
First Name:MARIO
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 1:161 WASHINGTON ST.
Mailing Address - Street 2:
Mailing Address - City:HAVERHILL
Mailing Address - State:MA
Mailing Address - Zip Code:01832-5418
Mailing Address - Country:US
Mailing Address - Phone:978-912-7466
Mailing Address - Fax:
Practice Address - Street 1:161 WASHINGTON ST.
Practice Address - Street 2:
Practice Address - City:HAVERHILL
Practice Address - State:MA
Practice Address - Zip Code:01832-5418
Practice Address - Country:US
Practice Address - Phone:978-912-7466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-16
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6276156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician