Basic Information
| Provider Information | |||||||||
| NPI: | 1871591180 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANZALONE | ||||||||
| FirstName: | SALVATORE | ||||||||
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| Credential: | MD, PACOG | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1454 MADISON AVE W | ||||||||
| Address2: | |||||||||
| City: | IMMOKALEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341422200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396583064 | ||||||||
| FaxNumber: | 2396583175 | ||||||||
| Practice Location | |||||||||
| Address1: | 3425 10TH ST N | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341033866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392621066 | ||||||||
| FaxNumber: | 2392622031 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2005 | ||||||||
| LastUpdateDate: | 11/29/2016 | ||||||||
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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 | 208000000X | ME117687 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 010865500 | 05 | FL | MEDICAID | 06032A | 01 | PA | EPSDT | OTHER | 1158726 | 05 | PA | MEDICAID |