Provider Demographics
NPI:1629073804
Name:SALEN, SAMUEL (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:SALEN
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 1:1902 ROYALTY DR
Mailing Address - Street 2:STE 220
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-3056
Mailing Address - Country:US
Mailing Address - Phone:909-570-3108
Mailing Address - Fax:909-469-6741
Practice Address - Street 1:1902 ROYALTY DR
Practice Address - Street 2:STE 220
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3056
Practice Address - Country:US
Practice Address - Phone:909-570-3108
Practice Address - Fax:909-469-6741
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG200482085B0100X, 2085R0202X, 2085R0204X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G200480Medicaid
CAA40827Medicare UPIN
CA00G200480Medicaid
CA00G200480Medicare PIN