Basic Information
| Provider Information | |||||||||
| NPI: | 1841270519 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SALLABERRY | ||||||||
| FirstName: | JORGE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3299 | ||||||||
| Address2: | |||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897023299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7752220044 | ||||||||
| FaxNumber: | 8887000187 | ||||||||
| Practice Location | |||||||||
| Address1: | 1930 E ORMAN AVE | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810043553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195618574 | ||||||||
| FaxNumber: | 7195649180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2006 | ||||||||
| LastUpdateDate: | 01/18/2022 | ||||||||
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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 | 208M00000X | M-14732 | ID | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 12639 | NV | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 12639 | UT | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 41468 | CO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 56972377 | 05 | CO | MEDICAID |