Healthcare Provider Details

I. General information

NPI: 1982672523
Provider Name (Legal Business Name): ARMANDO R SALLAVANTI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 11/22/2021
Certification Date: 11/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 S MAIN ST
OLD FORGE PA
18518-1606
US

IV. Provider business mailing address

315 S MAIN ST
OLD FORGE PA
18518-1606
US

V. Phone/Fax

Practice location:
  • Phone: 570-457-8364
  • Fax: 570-457-9635
Mailing address:
  • Phone: 570-457-8364
  • Fax: 570-457-9635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS009292L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier001688188
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: