Provider Demographics
NPI:1598710170
Name:SLATER, KENNETH C (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:C
Last Name:SLATER
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:PO BOX 3997
Mailing Address - Street 2:
Mailing Address - City:WISE
Mailing Address - State:VA
Mailing Address - Zip Code:24293-3997
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:113 SHORT ST
Practice Address - Street 2:
Practice Address - City:POUNDING MILL
Practice Address - State:VA
Practice Address - Zip Code:24637-4278
Practice Address - Country:US
Practice Address - Phone:540-212-6090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101051566204D00000X, 2083A0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAPENDINGMedicaid
VAPENDINGMedicaid
VAB34613Medicare UPIN