Provider Demographics
NPI:1689084022
Name:POLACCO, MARC (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:POLACCO
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 1:902 PONDER PLACE CT
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3115
Mailing Address - Country:US
Mailing Address - Phone:706-364-3223
Mailing Address - Fax:
Practice Address - Street 1:902 PONDER PLACE CT
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3115
Practice Address - Country:US
Practice Address - Phone:706-364-3223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-07
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA85522207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty