Provider Demographics
NPI:1376808485
Name:LAIES, SLAVITA MARIA (MD)
Entity Type:Individual
Prefix:DR
First Name:SLAVITA
Middle Name:MARIA
Last Name:LAIES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:892 AEROVISTA PL STE 210
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-8054
Practice Address - Country:US
Practice Address - Phone:805-549-8023
Practice Address - Fax:805-549-8252
Is Sole Proprietor?:No
Enumeration Date:2012-07-05
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301101329207R00000X
ORMD171761207R00000X, 208M00000X
NMMD2020-0591390200000X
CAA145021207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORMD171761OtherOREGON LICENSE
ORFL5441085OtherDEA
ORFL5441085OtherDEA