Basic Information
| Provider Information | |||||||||
| NPI: | 1528040409 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SALIB | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | YASSA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 749 N HIGHWAY 29 | ||||||||
| Address2: | |||||||||
| City: | CANTONMENT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325339596 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8509374004 | ||||||||
| FaxNumber: | 8509374006 | ||||||||
| Practice Location | |||||||||
| Address1: | 749 N HIGHWAY 29 | ||||||||
| Address2: | |||||||||
| City: | CANTONMENT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325339596 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8509374004 | ||||||||
| FaxNumber: | 8509374006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 07/24/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME87968 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 44104 | 01 | FL | BCBS FL | OTHER | 270450100 | 05 | FL | MEDICAID | ME87968 | 01 | FL | MEDICAL LICENSE NUMBER | OTHER | 810657750 | 01 | FL | CIGNA | OTHER | K8350 | 01 | FL | MEDICARE GROUP | OTHER |