Provider Demographics
NPI:1952399669
Name:POLO, JUAN GUSTAVO (MD)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:GUSTAVO
Last Name:POLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:234 E GRAY ST
Mailing Address - Street 2:STE. 670
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1900
Mailing Address - Country:US
Mailing Address - Phone:502-629-4525
Mailing Address - Fax:502-629-4529
Practice Address - Street 1:234 E GRAY ST
Practice Address - Street 2:STE. 670
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1900
Practice Address - Country:US
Practice Address - Phone:502-629-4525
Practice Address - Fax:502-629-4529
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36067207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200489040OtherANTHEM INDIANA MEDICAID- NORTON ICC
KY64017098Medicaid
IN200489040Medicaid
KY200489040OtherMD WISE- NORTON ICC
KY1128117OtherPASSPORT
KY200489040OtherHEALTHY INDIANA PLAN- NORTON ICC
KY31K4, 000000179689OtherANTHEM
INP00838101OtherRRMCR - NICC
002045573-002OtherUNITED HEALTHCARE
KY017376OtherSIHO - NORTON ICC
KY5832707OtherAETNA
KYP00362331OtherRRMCR - NICC
KY000000381954OtherANTHEM - NORTON ICC
IN200489040Medicaid
IN196290HHMedicare PIN
KY200489040OtherHEALTHY INDIANA PLAN- NORTON ICC
IN200489040OtherANTHEM INDIANA MEDICAID- NORTON ICC