Healthcare Provider Details

I. General information

NPI: 1942497466
Provider Name (Legal Business Name): JAMES JONATHAN SLATER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2007
Last Update Date: 05/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2611 CHARLEVOIX AVE
PETOSKEY MI
49770-8524
US

IV. Provider business mailing address

2611 CHARLEVOIX AVE
PETOSKEY MI
49770-8524
US

V. Phone/Fax

Practice location:
  • Phone: 231-348-5900
  • Fax: 231-348-5901
Mailing address:
  • Phone: 231-348-5900
  • Fax: 231-348-5901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number5101015870
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: