Provider Demographics
NPI:1316620313
Name:POLANCO TAVERAS, JULIO
Entity type:Individual
Prefix:
First Name:JULIO
Middle Name:
Last Name:POLANCO TAVERAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 BROAD ST APT 1241
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06901-5004
Mailing Address - Country:US
Mailing Address - Phone:845-200-8233
Mailing Address - Fax:
Practice Address - Street 1:180 BROAD ST APT 1241
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06901-5004
Practice Address - Country:US
Practice Address - Phone:845-200-8233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY340160164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse