Healthcare Provider Details

I. General information

NPI: 1447320049
Provider Name (Legal Business Name): KENNETH RAY SLADKIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 02/08/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

192 VILLAGE DR
JACKSONVILLE NC
28546-7299
US

IV. Provider business mailing address

8132 KING HELIE BLVD
NEW PORT RICHEY FL
34653-1435
US

V. Phone/Fax

Practice location:
  • Phone: 910-577-1400
  • Fax:
Mailing address:
  • Phone: 727-834-3959
  • Fax: 727-816-1964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberME57376
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: