Provider Demographics
NPI:1306899026
Name:POLANCO, ENRIQUE D (MD)
Entity type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:D
Last Name: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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1223 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2607
Practice Address - Country:US
Practice Address - Phone:321-312-3487
Practice Address - Fax:321-956-2542
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89353207RC0000X
FLME894353207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
7388727OtherAETNA
FL274442200Medicaid
FL41003OtherBCBS OF FL
FLP00382944OtherRR MEDICARE
FLP01164167OtherFL RR MEDICARE
FLU6951WOtherHFMG MEDICARE