=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295753267
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHAEL SALCEDO DPM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2006
-----------------------------------------------------
Last Update Date | 12/11/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3665 PARK PL W SUITE 200
-----------------------------------------------------
City | MISHAWAKA
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46545-3566
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-271-1030
-----------------------------------------------------
Fax | 574-271-1032
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3665 PARK PL W SUITE 200
-----------------------------------------------------
City | MISHAWAKA
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46545-3566
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-271-1030
-----------------------------------------------------
Fax | 574-271-1032
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MICHAEL SALCEDO
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 574-271-1030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 07000626A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 07000626A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------