Healthcare Provider Details

I. General information

NPI: 1679640619
Provider Name (Legal Business Name): ELADIO A POLANCO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 CALLE CUPIDO URB. VENUS GARDENS
SAN JUAN PR
00926-4821
US

IV. Provider business mailing address

704 CALLE CUPIDO URB. VENUS GARDENS
SAN JUAN PR
00926-4821
US

V. Phone/Fax

Practice location:
  • Phone: 787-283-1313
  • Fax:
Mailing address:
  • Phone: 787-283-1313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170100000X
TaxonomyPh.D. Medical Genetics
License Number4835
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: