Provider Demographics
NPI:1922041995
Name:SALAZAR, JUAN CARLOS (MD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:CARLOS
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 1:5716 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-9648
Mailing Address - Country:US
Mailing Address - Phone:573-686-2127
Mailing Address - Fax:573-778-4156
Practice Address - Street 1:1140 HERSCHEL BESS BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3075
Practice Address - Country:US
Practice Address - Phone:573-686-1200
Practice Address - Fax:573-686-1029
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20001743582084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
431116734OtherUNITED BEHAVIORAL HEALTH
MO205345804Medicaid
461695OtherHEALTHLINK HMO
461695OtherHEALTHLINK PPO
461695OtherHEALTHLINK PPO