Healthcare Provider Details

I. General information

NPI: 1871869933
Provider Name (Legal Business Name): MARISSA SALAZAR CANTU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2012
Last Update Date: 02/17/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4502 MEDICAL DR
SAN ANTONIO TX
78229-4402
US

IV. Provider business mailing address

4502 MEDICAL DR
SAN ANTONIO TX
78229-4402
US

V. Phone/Fax

Practice location:
  • Phone: 210-358-2078
  • Fax: 210-358-1972
Mailing address:
  • Phone: 210-358-2078
  • Fax: 210-358-1972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2015015074
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2015015074
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code2080C0008X
TaxonomyChild Abuse Pediatrics Physician
License NumberS6584
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberS6584
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: