Provider Demographics
NPI:1407953177
Name:VANDERSLICE, DUANE E (MD)
Entity Type:Individual
Prefix:
First Name:DUANE
Middle Name:E
Last Name:VANDERSLICE
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 1:816 W MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-5631
Mailing Address - Country:US
Mailing Address - Phone:505-327-3634
Mailing Address - Fax:505-327-2104
Practice Address - Street 1:816 W MAPLE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5631
Practice Address - Country:US
Practice Address - Phone:505-327-3634
Practice Address - Fax:505-327-2104
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM83-134174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM22095Medicaid
NM2836OtherBLUE CROSS BLUE SHIELD
NM850364974OtherTAX ID
NM201010266OtherPRESBYTERIAN HEALTH/SALUD
NM22095Medicaid
NM2133964Medicare PIN