Provider Demographics
NPI:1659802205
Name:SLATTERY, TYLER
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:SLATTERY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4077 FIFTH AVE # MER35
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4077 FIFTH AVE # MER35
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2105
Practice Address - Country:US
Practice Address - Phone:619-294-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-24
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE5619213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery