Provider Demographics
NPI:1164564860
Name:SLADE, DIRK L (MD)
Entity Type:Individual
Prefix:
First Name:DIRK
Middle Name:L
Last Name:SLADE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:652 S MEDICAL CENTER DR
Practice Address - Street 2:STE 400
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-7049
Practice Address - Country:US
Practice Address - Phone:435-251-2650
Practice Address - Fax:435-251-2668
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0064980207XS0106X
UT2869891205207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery