Healthcare Provider Details

I. General information

NPI: 1033463708
Provider Name (Legal Business Name): HADEILY EVANGELINA SALAZAR HERNANDEZ M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2012
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 STATE ST
LA PORTE IN
46350-3115
US

IV. Provider business mailing address

PO BOX 1690
LA PORTE IN
46352-1690
US

V. Phone/Fax

Practice location:
  • Phone: 219-324-3431
  • Fax: 219-362-3802
Mailing address:
  • Phone: 219-326-2461
  • Fax: 219-325-6439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01074872A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: