Healthcare Provider Details

I. General information

NPI: 1700110921
Provider Name (Legal Business Name): STEPHEN EDWARD SLATTERY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2009
Last Update Date: 12/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17055 RUBEN LN
SANDY OR
97055-9276
US

IV. Provider business mailing address

10000 SE MAIN ST SUITE 116
PORTLAND OR
97216-2448
US

V. Phone/Fax

Practice location:
  • Phone: 503-668-8002
  • Fax: 503-668-5246
Mailing address:
  • Phone: 503-251-6292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A11657
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO126175
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: