Provider Demographics
NPI:1720275902
Name:POLO-PALMER, DOMINGA ANTONIA (RPT)
Entity Type:Individual
Prefix:MRS
First Name:DOMINGA
Middle Name:ANTONIA
Last Name:POLO-PALMER
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 SW 37TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-4220
Mailing Address - Country:US
Mailing Address - Phone:954-581-5492
Mailing Address - Fax:
Practice Address - Street 1:1950 SW 37TH AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-4220
Practice Address - Country:US
Practice Address - Phone:954-581-5492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT154612251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE7448ZMedicare UPIN