Provider Demographics
NPI:1477598258
Name:SLADICH, LAWRENCE J (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:J
Last Name:SLADICH
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 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-452-8040
Mailing Address - Fax:208-452-8056
Practice Address - Street 1:910 NW 16TH
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619
Practice Address - Country:US
Practice Address - Phone:208-452-8040
Practice Address - Fax:208-452-8056
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5535207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003952400Medicaid
C51388Medicare UPIN
ID003952400Medicaid