Provider Demographics
NPI:1669653291
Name:ROBERTO POLANCO MD PA
Entity Type:Organization
Organization Name:ROBERTO POLANCO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ONEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTALVO
Authorized Official - Suffix:
Authorized Official - Credentials:CPC,MA
Authorized Official - Phone:786-345-6991
Mailing Address - Street 1:PO BOX 655009
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33265-5009
Mailing Address - Country:US
Mailing Address - Phone:305-228-4422
Mailing Address - Fax:305-596-4422
Practice Address - Street 1:8501 SW 124TH AVE
Practice Address - Street 2:102A
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33183-4627
Practice Address - Country:US
Practice Address - Phone:305-228-4422
Practice Address - Fax:305-596-4422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-26
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME62015174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty