Basic Information
| Provider Information | |||||||||
| NPI: | 1922041995 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SALAZAR | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | CARLOS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5716 LAKE SHORE DR | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639019648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736862127 | ||||||||
| FaxNumber: | 5737784156 | ||||||||
| Practice Location | |||||||||
| Address1: | 1140 HERSCHEL BESS BLVD | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639013075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736861200 | ||||||||
| FaxNumber: | 5736861029 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 11/25/2015 | ||||||||
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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 | 2084P0800X | 2000174358 | MO | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | 2000174358 | MO | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 431116734 | 01 | UNITED BEHAVIORAL HEALTH | OTHER | 205345804 | 05 | MO | MEDICAID | 461695 | 01 | HEALTHLINK HMO | OTHER | 461695 | 01 | HEALTHLINK PPO | OTHER |