Provider Demographics
NPI:1902202096
Name:POLANCO ZACARIAS, VIARDA LICELOT (MD)
Entity Type:Individual
Prefix:
First Name:VIARDA
Middle Name:LICELOT
Last Name:POLANCO ZACARIAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 KINARD ST
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:SC
Mailing Address - Zip Code:29108-2909
Mailing Address - Country:US
Mailing Address - Phone:803-405-0220
Mailing Address - Fax:
Practice Address - Street 1:113 LINER DR
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-2311
Practice Address - Country:US
Practice Address - Phone:864-941-8170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-17
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMMD 37947 MD208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics