Basic Information
| Provider Information | |||||||||
| NPI: | 1548688476 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURGOS POLANCO | ||||||||
| FirstName: | NATALIA | ||||||||
| MiddleName: | D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 S FISKE BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329554306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212154910 | ||||||||
| FaxNumber: | 3219517408 | ||||||||
| Practice Location | |||||||||
| Address1: | 1223 GATEWAY DR STE 1F | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329012607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212154910 | ||||||||
| FaxNumber: | 3219562539 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2014 | ||||||||
| LastUpdateDate: | 10/31/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | ME140580 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | LK691 | 01 | FL | MEDICARE | OTHER | 103174600 | 05 | FL | MEDICAID |