Provider Demographics
NPI:1962944223
Name:POLANCO, BROWN (RDO)
Entity type:Individual
Prefix:
First Name:BROWN
Middle Name:
Last Name:POLANCO
Suffix:
Gender:M
Credentials:RDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327-329 ESSEX ST.
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01840-1410
Mailing Address - Country:US
Mailing Address - Phone:978-689-4402
Mailing Address - Fax:978-681-4504
Practice Address - Street 1:327-329 ESSEX ST.
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01840-1410
Practice Address - Country:US
Practice Address - Phone:978-689-4402
Practice Address - Fax:978-681-4504
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-17
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5807156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician