Provider Demographics
NPI:1386726859
Name:EVETTE POLCZYNSKI, MD, LLC
Entity type:Organization
Organization Name:EVETTE POLCZYNSKI, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EVETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:POLCZYNSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-264-9138
Mailing Address - Street 1:PO BOX 3483
Mailing Address - Street 2:116 ROCK RIDGE CT
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-3483
Mailing Address - Country:US
Mailing Address - Phone:970-264-9138
Mailing Address - Fax:970-264-2219
Practice Address - Street 1:103 PAGOSA ST
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147
Practice Address - Country:US
Practice Address - Phone:970-264-2218
Practice Address - Fax:970-264-2219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO42002207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty