=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457550261
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARIO R. SALAZAR, M.D., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2007
-----------------------------------------------------
Last Update Date | 08/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7979 W VIRGINIA DR
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75237-3798
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-296-4458
-----------------------------------------------------
Fax | 972-875-5121
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 301
-----------------------------------------------------
City | ENNIS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75120-0301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-296-4458
-----------------------------------------------------
Fax | 972-875-5121
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARIO REY SALAZAR
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 972-296-4458
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | M7587
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------