Healthcare Provider Details

I. General information

NPI: 1952353971
Provider Name (Legal Business Name): EDWIN MANUEL SALAMANCA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2221 NORTH BLVD W
DAVENPORT FL
33837-8990
US

IV. Provider business mailing address

PO BOX 667
DAVENPORT FL
33836-0667
US

V. Phone/Fax

Practice location:
  • Phone: 863-421-7600
  • Fax: 863-421-7551
Mailing address:
  • Phone: 863-421-7600
  • Fax: 863-421-7551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME64430
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: