Provider Demographics
NPI:1154365807
Name:SALAK, SUSAN L (DPM, PC)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:L
Last Name:SALAK
Suffix:
Gender:F
Credentials:DPM, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 S MAIN ST
Mailing Address - Street 2:SUITE 9
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18701-1734
Mailing Address - Country:US
Mailing Address - Phone:570-823-0187
Mailing Address - Fax:570-823-0188
Practice Address - Street 1:34 S MAIN ST
Practice Address - Street 2:SUITE 9
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18701-1734
Practice Address - Country:US
Practice Address - Phone:570-823-0187
Practice Address - Fax:570-823-0188
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003648L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASA1626367OtherBLUE SHIELD
PA803141OtherHMO
PA01452827Medicaid
PA0851310001Medicare NSC
PA01452827Medicaid
PASA678740Medicare ID - Type Unspecified