Provider Demographics
NPI:1942699277
Name:POLANCO, JORGE L SR
Entity Type:Individual
Prefix:MR
First Name:JORGE
Middle Name:L
Last Name:POLANCO
Suffix:SR
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:HC 3 BOX 3377
Mailing Address - Street 2:
Mailing Address - City:FLORIDA
Mailing Address - State:PR
Mailing Address - Zip Code:00650-9667
Mailing Address - Country:US
Mailing Address - Phone:939-288-6335
Mailing Address - Fax:
Practice Address - Street 1:1 CALLE PLAYERA NUM.114
Practice Address - Street 2:URB. COSTAS DEL ATLANTICO
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00612-0061
Practice Address - Country:US
Practice Address - Phone:939-288-6335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-09
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician