Provider Demographics
NPI:1295392553
Name:SLADE, JOHNNY (MD)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:SLADE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733
Mailing Address - Country:US
Mailing Address - Phone:631-476-4000
Mailing Address - Fax:631-476-4003
Practice Address - Street 1:11 BRIDGE RD
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733
Practice Address - Country:US
Practice Address - Phone:631-476-4000
Practice Address - Fax:631-476-4003
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY176120207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine