Provider Demographics
NPI:1366421612
Name:SALVAGGIO, MARK A (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:SALVAGGIO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MEDICAL PARK DR STE 400
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-0939
Mailing Address - Country:US
Mailing Address - Phone:704-786-1108
Mailing Address - Fax:704-782-1826
Practice Address - Street 1:200 MEDICAL PARK DR STE 400
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-0939
Practice Address - Country:US
Practice Address - Phone:704-786-1108
Practice Address - Fax:704-782-1826
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-14
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101238654174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010195390Medicaid
VA183841OtherANTHEM
VA008743S28Medicare PIN