Provider Demographics
NPI:1346546785
Name:SALEM, NIZAR
Entity Type:Individual
Prefix:
First Name:NIZAR
Middle Name:
Last Name:SALEM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:NIZAR
Other - Middle Name:
Other - Last Name:SALEM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:525 3RD ST STE 304
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-3082
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:190 E BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6241
Practice Address - Country:US
Practice Address - Phone:208-381-5015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-02
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV14018207R00000X
UT9410265-1205207R00000X
CODR.0053425207R00000X, 208M00000X
MA286944207R00000X
IDM-13868207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP01301932OtherRAILROAD MEDICARE
CO87089700Medicaid
CO334897YL2GMedicare PIN
NVFI099YMedicare PIN