Healthcare Provider Details

I. General information

NPI: 1942542295
Provider Name (Legal Business Name): ROBERTO ANDRES SALAS FRAGOMENI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2013
Last Update Date: 07/12/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 LOGAN AVENUE
WATERLOO IA
50703
US

IV. Provider business mailing address

1825 LOGAN AVE
WATERLOO IA
50703
US

V. Phone/Fax

Practice location:
  • Phone: 319-235-3941
  • Fax:
Mailing address:
  • Phone: 206-512-0347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License NumberMD-47793
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD-47793
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberML60370384
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: