Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207QA0505X | Family Doctor - Adult Medicine | PA9112633 | FL |
N | 207RC0200X | Critical Care Medicine | PA9112633 | FL |
NPI | 1013558188 |
---|---|
Provider Name | Gustavo Emil Polanco Hernandez |
First Address | Hialeah, FL 33015-7239 |
Second Address | Miami, FL 33136-1005 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/09/2019 |
Last Update Date | 13/11/2020 |