Provider Demographics
NPI:1457849754
Name:SALAZAR, JUAN (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:
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 1:4001 COLISEUM DR STE 300
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-6257
Mailing Address - Country:US
Mailing Address - Phone:757-827-2025
Mailing Address - Fax:757-275-9802
Practice Address - Street 1:4001 COLISEUM DR STE 300
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-6257
Practice Address - Country:US
Practice Address - Phone:757-827-2025
Practice Address - Fax:757-275-9802
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-23
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101272292207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program