Provider Demographics
NPI:1689677965
Name:SALATICH, DALE GRAHAM (MD)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:GRAHAM
Last Name:SALATICH
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 1:745 N MAGNOLIA AVE.
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-3835
Mailing Address - Country:US
Mailing Address - Phone:407-299-7333
Mailing Address - Fax:
Practice Address - Street 1:745 N MAGNOLIA AVE.
Practice Address - Street 2:SUITE 201
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-3835
Practice Address - Country:US
Practice Address - Phone:407-299-7333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-31
Last Update Date:2013-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME53091207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL049534400Medicaid
FL623763OtherAENTA PROVIDER ID
FL05974OtherBLUE CROSS BLUE SHIELD
FL4071383OtherAETNA PROVIDER ID
FLFEINOther593490701
FLB63895Medicare UPIN
FL623763OtherAENTA PROVIDER ID