Provider Demographics
NPI:1003915620
Name:SALAZAR, MARIO A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:A
Last Name:SALAZAR
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 1:3048 N HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-4704
Mailing Address - Country:US
Mailing Address - Phone:773-237-7795
Mailing Address - Fax:773-237-7547
Practice Address - Street 1:3048 N HARLEM AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-4704
Practice Address - Country:US
Practice Address - Phone:773-237-7795
Practice Address - Fax:773-237-7547
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-049655207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL21605529OtherBLUE CROSS/BLUE SHIELD
IL036049655Medicaid
IL363129476OtherTAX ID
IL363129476OtherTAX ID
IL036049655Medicaid