Healthcare Provider Details

I. General information

NPI: 1083690036
Provider Name (Legal Business Name): VENEZELA THOMAS SLADE-HARTMAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 10/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4692 BROWNSBORO RD
WINSTON SALEM NC
27106-3410
US

IV. Provider business mailing address

4692 BROWNSBORO ROAD
WINSTON-SALEM NC
27106
US

V. Phone/Fax

Practice location:
  • Phone: 336-251-1114
  • Fax: 336-251-1116
Mailing address:
  • Phone: 336-251-1114
  • Fax: 336-251-1116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number200201189
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: