Provider Demographics
NPI:1538158761
Name:PEREZ POLANCO, JORGE L (MD)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:L
Last Name:PEREZ POLANCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 271085
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33688-1085
Mailing Address - Country:US
Mailing Address - Phone:407-788-1906
Mailing Address - Fax:239-574-1451
Practice Address - Street 1:119 OAKFIELD DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5779
Practice Address - Country:US
Practice Address - Phone:813-681-0038
Practice Address - Fax:239-574-1451
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94246207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL274617400Medicaid
FLP00288529OtherRAILROAD PROVIDER NUMBER
FL30018OtherBCBS
FL1865320OtherCIGNA
FLP00288529OtherRAILROAD PROVIDER NUMBER
FL274617400Medicaid