Provider Demographics
NPI:1184704595
Name:SALAZAR, VIVIAN W
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:W
Last Name:SALAZAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 RIDGE AVE STE 1223
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1700
Mailing Address - Country:US
Mailing Address - Phone:847-570-2040
Mailing Address - Fax:
Practice Address - Street 1:915 S WAUKEGAN RD STE 200
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-2654
Practice Address - Country:US
Practice Address - Phone:847-234-8866
Practice Address - Fax:847-234-4682
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-081456207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036081456Medicaid
ILCA4079Medicare ID - Type UnspecifiedRR GROUP #
IL800800Medicare ID - Type UnspecifiedGROUP #
ILL89375Medicare ID - Type UnspecifiedINDIVIDUAL #
IL809840Medicare ID - Type UnspecifiedGROUP #
ILL75601Medicare ID - Type UnspecifiedINDIVIDUAL #