Provider Demographics
NPI:1487226387
Name:SLACK, JONATHAN CORWIN (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:CORWIN
Last Name:SLACK
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 1:9500 EUCLID AVE L2
Mailing Address - Street 2:OFFICE 216
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44195
Mailing Address - Country:US
Mailing Address - Phone:216-448-4899
Mailing Address - Fax:
Practice Address - Street 1:9500 EUCLID AVE L2
Practice Address - Street 2:OFFICE 216
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195
Practice Address - Country:US
Practice Address - Phone:216-448-4899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-12
Last Update Date:2023-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA287182207ZP0213X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0213XAllopathic & Osteopathic PhysiciansPathologyPediatric Pathology