Healthcare Provider Details

I. General information

NPI: 1124461546
Provider Name (Legal Business Name): JONATHAN L SLADKY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2013
Last Update Date: 02/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1319 PUNAHOU ST
HONOLULU HI
96826-1001
US

IV. Provider business mailing address

1319 PUNAHOU ST
HONOLULU HI
96826-1001
US

V. Phone/Fax

Practice location:
  • Phone: 419-787-1084
  • Fax:
Mailing address:
  • Phone: 419-787-1084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD-18721
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License NumberMD-18721
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: