Provider Demographics
NPI:1396945317
Name:POLIDORO, ANGELIQUE RENAE (DO)
Entity type:Individual
Prefix:DR
First Name:ANGELIQUE
Middle Name:RENAE
Last Name:POLIDORO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:ANGELIQUE
Other - Middle Name:RENAE
Other - Last Name:DENAXAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:19531 COCHRAN BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-2081
Practice Address - Country:US
Practice Address - Phone:941-255-3535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2010-01605207Q00000X, 208D00000X
FLOS17556207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2010-01605OtherMEDICAL LICENSE
NC5916841Medicaid
NJD09076700OtherCDS
NJD09076700OtherCDS
NC5916841Medicaid