Basic Information
| Provider Information | |||||||||
| NPI: | 1396059150 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZULETA | ||||||||
| FirstName: | ANDRES | ||||||||
| MiddleName: | GONZALO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8100 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973030900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033992424 | ||||||||
| FaxNumber: | 5033757429 | ||||||||
| Practice Location | |||||||||
| Address1: | 2020 CAPITOL ST NE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973010698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033992424 | ||||||||
| FaxNumber: | 5033757429 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2010 | ||||||||
| LastUpdateDate: | 06/13/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 272646 | NY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | L.3596R | AL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 053530 | CT | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD191405 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 500762457 | 05 | OR | MEDICAID |