Provider Demographics
NPI:1245307453
Name:PEREZ POLANCO, AIVLYS (MD)
Entity type:Individual
Prefix:
First Name:AIVLYS
Middle Name:
Last Name:PEREZ 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 1:151 SOUTHHALL LN
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7176
Mailing Address - Country:US
Mailing Address - Phone:407-875-2080
Mailing Address - Fax:407-650-3544
Practice Address - Street 1:8209 STATE ROAD 54
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34655-3016
Practice Address - Country:US
Practice Address - Phone:727-569-1055
Practice Address - Fax:727-569-1505
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME130895207ND0900X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIV956ZMedicare PIN