Provider Demographics
NPI:1225012867
Name:SALAZAR, JORGE E (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:E
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-312-3316
Mailing Address - Fax:321-768-5031
Practice Address - Street 1:1223 GATEWAY DR STE 1A
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2607
Practice Address - Country:US
Practice Address - Phone:321-312-3316
Practice Address - Fax:321-768-5031
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME56809207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL09930XOtherFL MEDICARE
FL0634174000Medicaid
FL110072529OtherRR MEDICARE
FL09930YMedicare PIN