Provider Demographics
NPI:1548624539
Name:POLANCO, LIDIANNY (DO)
Entity type:Individual
Prefix:
First Name:LIDIANNY
Middle Name:
Last Name:POLANCO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 ELY PARK BLVD APT 56-2
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-1447
Mailing Address - Country:US
Mailing Address - Phone:201-401-7923
Mailing Address - Fax:
Practice Address - Street 1:850 PETER BRYCE BLVD
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-7457
Practice Address - Country:US
Practice Address - Phone:205-348-1770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-06
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO1984207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program