Provider Demographics
NPI:1114997491
Name:SALAZAR, OMAR MAURICIO (MD)
Entity Type:Individual
Prefix:DR
First Name:OMAR
Middle Name:MAURICIO
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 1:2160 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS DEPT.
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1410
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:6825 SW 87TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-2502
Practice Address - Country:US
Practice Address - Phone:786-476-8854
Practice Address - Fax:786-476-8855
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010735912085R0001X
FLME1051312085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14885OtherDIMENSION HEALTH
FLDRT2WOtherBCBS
MIOS073591OtherBCBS
FL4070264OtherAETNA
MI4232460Medicaid
FL69640OtherHEALTH SUN HEALTH PLANS
FL1450460OtherWELLCARE
FL3826585OtherCIGNA
MI125080OtherCARE CHOICES
300108773OtherRR MEDICARE
MI3823585004005OtherCIGNA
FLQMP000005330019OtherMOLINA
FL368447OtherAVMED
MI4232460Medicaid
FLQMP000005330019OtherMOLINA