Healthcare Provider Details

I. General information

NPI: 1528040409
Provider Name (Legal Business Name): MARY YASSA SALIB MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 07/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

749 N HIGHWAY 29
CANTONMENT FL
32533-9596
US

IV. Provider business mailing address

749 N HIGHWAY 29
CANTONMENT FL
32533-9596
US

V. Phone/Fax

Practice location:
  • Phone: 850-937-4004
  • Fax: 850-937-4006
Mailing address:
  • Phone: 850-937-4004
  • Fax: 850-937-4006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME87968
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: