Provider Demographics
NPI:1265594493
Name:SALAZAR, ANDRES
Entity type:Individual
Prefix:
First Name:ANDRES
Middle Name:
Last Name:SALAZAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3621 LIGON RD
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-5238
Mailing Address - Country:US
Mailing Address - Phone:410-750-7954
Mailing Address - Fax:
Practice Address - Street 1:3621 LIGON RD
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-5238
Practice Address - Country:US
Practice Address - Phone:410-486-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0051051207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD692900100Medicaid
MDG01467A01Medicare ID - Type UnspecifiedINDIVIDUAL