1922041995 NPI number — DR. JUAN CARLOS SALAZAR M.D.

Table of content: DR. JUAN CARLOS SALAZAR M.D. (NPI 1922041995)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922041995 NPI number — DR. JUAN CARLOS SALAZAR M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SALAZAR
Provider First Name:
JUAN
Provider Middle Name:
CARLOS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922041995
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5716 LAKE SHORE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POPLAR BLUFF
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63901-9648
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-686-2127
Provider Business Mailing Address Fax Number:
573-778-4156

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1140 HERSCHEL BESS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POPLAR BLUFF
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63901-3075
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-686-1200
Provider Business Practice Location Address Fax Number:
573-686-1029
Provider Enumeration Date:
06/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  2000174358 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0804X , with the licence number: 2000174358 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 431116734 . This is a "UNITED BEHAVIORAL HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 205345804 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 461695 . This is a "HEALTHLINK HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 461695 . This is a "HEALTHLINK PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 019209600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com