Healthcare Provider Details

I. General information

NPI: 1902202096
Provider Name (Legal Business Name): VIARDA LICELOT POLANCO ZACARIAS M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2014
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 LINER DR
GREENWOOD SC
29646-2311
US

IV. Provider business mailing address

2525 KINARD ST
NEWBERRY SC
29108-2909
US

V. Phone/Fax

Practice location:
  • Phone: 864-941-8170
  • Fax:
Mailing address:
  • Phone: 803-405-0220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMMD 37947 MD
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: