Provider Demographics
NPI:1992052450
Name:POLO BOLANO, MARIBEL S
Entity type:Individual
Prefix:MRS
First Name:MARIBEL
Middle Name:S
Last Name:POLO BOLANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16103 POWELLS COVE BLVD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11357-1404
Mailing Address - Country:US
Mailing Address - Phone:347-965-8028
Mailing Address - Fax:
Practice Address - Street 1:13244 60TH AVE
Practice Address - Street 2:2 FLOOR
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-5250
Practice Address - Country:US
Practice Address - Phone:347-520-3820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-14
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist