=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003358672
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PABLO SALAZAR SAEZ M.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2016
-----------------------------------------------------
Last Update Date | 10/17/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5841 S MARYLAND AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60637-1443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-702-1234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 808 W UNIVERSITY LN UNIT 3B
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60608-3789
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-914-3240
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | 125069725
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------