Provider Demographics
NPI:1821502162
Name:POLO PEREZ, ISMAEL PAVEL
Entity Type:Individual
Prefix:
First Name:ISMAEL
Middle Name:PAVEL
Last Name:POLO PEREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6794 SW 152ND CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-2216
Mailing Address - Country:US
Mailing Address - Phone:713-391-7800
Mailing Address - Fax:956-389-4603
Practice Address - Street 1:2101 PEASE ST STE 200
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-8307
Practice Address - Country:US
Practice Address - Phone:956-296-1590
Practice Address - Fax:956-389-4603
Is Sole Proprietor?:No
Enumeration Date:2017-11-22
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME161829207R00000X
TX16-469246ZC0007X
390200000X
TXT6678208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program