Provider Demographics
NPI:1609850411
Name:POLANCO, JOSE ROMAN (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:ROMAN
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 1:39 BARTLETT AVE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02905-1334
Mailing Address - Country:US
Mailing Address - Phone:401-529-3571
Mailing Address - Fax:
Practice Address - Street 1:31 ROCHE BROS WAY
Practice Address - Street 2:
Practice Address - City:NORTH EASTON
Practice Address - State:MA
Practice Address - Zip Code:02356-1032
Practice Address - Country:US
Practice Address - Phone:508-894-8730
Practice Address - Fax:508-894-8732
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD10514207R00000X
MA273647207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS400453494OtherMEDICARE
MA110131381AMedicaid
RI7009048Medicaid