Provider Demographics
NPI:1578571667
Name:SALAZAR, JESSE (OD)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:SALAZAR
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3802 JOE RAMSEY BLVD E
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75401-7711
Mailing Address - Country:US
Mailing Address - Phone:903-454-0471
Mailing Address - Fax:903-450-4332
Practice Address - Street 1:3802 JOE RAMSEY BLVD E
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75401-7711
Practice Address - Country:US
Practice Address - Phone:903-454-0471
Practice Address - Fax:903-450-4332
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3683TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8B8611Medicare PIN
TX5166760001Medicare NSC
TXT15705Medicare UPIN