Provider Demographics
NPI:1336771260
Name:RODRIGUEZ POLANCO, SAMUEL ANTONIO (SA-C)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ANTONIO
Last Name:RODRIGUEZ POLANCO
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8824 242ND ST
Mailing Address - Street 2:
Mailing Address - City:BELLEROSE
Mailing Address - State:NY
Mailing Address - Zip Code:11426-1241
Mailing Address - Country:US
Mailing Address - Phone:781-346-7191
Mailing Address - Fax:
Practice Address - Street 1:8824 242ND ST
Practice Address - Street 2:
Practice Address - City:BELLEROSE
Practice Address - State:NY
Practice Address - Zip Code:11426-1241
Practice Address - Country:US
Practice Address - Phone:781-346-7191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-08
Last Update Date:2020-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18-152246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant