Provider Demographics
NPI:1922529296
Name:POLANCO, CRYSTABEL (MD)
Entity Type:Individual
Prefix:
First Name:CRYSTABEL
Middle Name:
Last Name:POLANCO
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 1:1 PAULINE DR
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-3123
Mailing Address - Country:US
Mailing Address - Phone:862-621-5883
Mailing Address - Fax:
Practice Address - Street 1:63 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-8406
Practice Address - Country:US
Practice Address - Phone:973-574-8688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10855800208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics