Provider Demographics
NPI:1528065059
Name:SALCEDO, MICHAEL (DPM)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SALCEDO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3665 PARK PL W
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3566
Mailing Address - Country:US
Mailing Address - Phone:574-271-1030
Mailing Address - Fax:574-271-1032
Practice Address - Street 1:3665 PARK PL W
Practice Address - Street 2:SUITE 200
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3566
Practice Address - Country:US
Practice Address - Phone:574-271-1030
Practice Address - Fax:574-271-1032
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2021-06-04
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
IN07000626A213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100090940Medicaid
0435320001Medicare NSC
IN100090940Medicaid
T86623Medicare UPIN