Healthcare Provider Details

I. General information

NPI: 1205634557
Provider Name (Legal Business Name): JUAN RAFAEL DAVID POLANCO LOZADA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2025
Last Update Date: 03/07/2025
Certification Date: 03/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 MICHIGAN AVE NW
WASHINGTON DC
20010-2916
US

IV. Provider business mailing address

1400 NW 10TH AVE APT 1814
MIAMI FL
33136-1043
US

V. Phone/Fax

Practice location:
  • Phone: 888-884-2327
  • Fax:
Mailing address:
  • Phone: 203-893-8196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: