Healthcare Provider Details

I. General information

NPI: 1841270519
Provider Name (Legal Business Name): JORGE L SALLABERRY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 01/18/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 E ORMAN AVE
PUEBLO CO
81004-3553
US

IV. Provider business mailing address

PO BOX 3299
CARSON CITY NV
89702-3299
US

V. Phone/Fax

Practice location:
  • Phone: 719-561-8574
  • Fax: 719-564-9180
Mailing address:
  • Phone: 775-222-0044
  • Fax: 888-700-0187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number41468
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberM-14732
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number12639
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number12639
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: