Provider Demographics
NPI:1679591838
Name:SALAZAR, SERGIO AGUSTIN (MD)
Entity type:Individual
Prefix:
First Name:SERGIO
Middle Name:AGUSTIN
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 1:3400 QUADRANGLE BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-1492
Mailing Address - Country:US
Mailing Address - Phone:407-266-3627
Mailing Address - Fax:407-882-4799
Practice Address - Street 1:3400 QUADRANGLE BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-1492
Practice Address - Country:US
Practice Address - Phone:407-266-3627
Practice Address - Fax:407-882-4799
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN21574207R00000X
FLME103578207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCZ191ZMedicare PIN
FLCZ191ZMedicare PIN
TN33917OtherTLC
E90250Medicare UPIN
P00263009OtherRAILROAD MEDICARE
TN3328536Medicaid
TN3328536Medicare PIN
FLCZ191YMedicare PIN