Provider Demographics
NPI:1710956818
Name:POLANCO, LETICIA A (MD)
Entity Type:Individual
Prefix:DR
First Name:LETICIA
Middle Name:A
Last Name:POLANCO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:769 MEDICAL CENTER CT
Mailing Address - Street 2:STE 303
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-6602
Mailing Address - Country:US
Mailing Address - Phone:858-499-2600
Mailing Address - Fax:619-585-4390
Practice Address - Street 1:525 3RD AVE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-5616
Practice Address - Country:US
Practice Address - Phone:858-499-2600
Practice Address - Fax:619-585-4390
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76528207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A765280Medicaid
CA00A765280Medicaid
CAWA76528AMedicare ID - Type Unspecified