Provider Demographics
NPI:1831177930
Name:SALAZAR, IVAN R (PT)
Entity type:Individual
Prefix:MR
First Name:IVAN
Middle Name:R
Last Name:SALAZAR
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1004
Mailing Address - Street 2:BARRON DR
Mailing Address - City:INSTITUTE
Mailing Address - State:WV
Mailing Address - Zip Code:25112-1004
Mailing Address - Country:US
Mailing Address - Phone:304-766-4869
Mailing Address - Fax:304-766-4867
Practice Address - Street 1:BARRON DR
Practice Address - Street 2:
Practice Address - City:INSTITUTE
Practice Address - State:WV
Practice Address - Zip Code:25112-1004
Practice Address - Country:US
Practice Address - Phone:304-766-4869
Practice Address - Fax:304-766-4867
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV000674225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0001722910OtherMTN ST BC/BS PROVIDER
WV000674OtherWV BD OF PT
WV0157318000Medicaid