Basic Information
| Provider Information | |||||||||
| NPI: | 1730347345 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SALAS-VEGA | ||||||||
| FirstName: | MARIANA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 575 MAIN ST FL 2 | ||||||||
| Address2: | ATTN: CREDENTIALING DEPT | ||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064572845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603476971 | ||||||||
| FaxNumber: | 8606386831 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 SHAWS CV | ||||||||
| Address2: | |||||||||
| City: | NEW LONDON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604478304 | ||||||||
| FaxNumber: | 8604438720 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2008 | ||||||||
| LastUpdateDate: | 08/03/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | TRN12337 | FL | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 390200000X | TN | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 051831 | CT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 004236346 | 05 | CT | MEDICAID |