Healthcare Provider Details

I. General information

NPI: 1376808485
Provider Name (Legal Business Name): SLAVITA MARIA LAIES M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2012
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

632 DEL PRADO BLVD N STE 1
CAPE CORAL FL
33909-2278
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-468-8076
  • Fax: 239-468-7938
Mailing address:
  • Phone: 239-468-8076
  • Fax: 239-468-7938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD171761
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA145021
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberME122906
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD171761
License Number StateOR
# 5
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMD2020-0591
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: