Basic Information
| Provider Information | |||||||||
| NPI: | 1821502162 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POLO PEREZ | ||||||||
| FirstName: | ISMAEL | ||||||||
| MiddleName: | PAVEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2102 TREASURE HL BLVD | ||||||||
| Address2: | |||||||||
| City: | HARLINGEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785508736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9562961590 | ||||||||
| FaxNumber: | 9563894603 | ||||||||
| Practice Location | |||||||||
| Address1: | 2101 PEASE ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | HARLINGEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785508307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9562961590 | ||||||||
| FaxNumber: | 9563894603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2017 | ||||||||
| LastUpdateDate: | 07/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZC0007X | 16-469 | TX | N | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208M00000X | T6678 | TX | Y | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.