Provider Demographics
NPI:1710970371
Name:SLOTHOUBER, WAYNE G (OD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:G
Last Name:SLOTHOUBER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5129 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-2670
Mailing Address - Country:US
Mailing Address - Phone:605-332-2231
Mailing Address - Fax:605-330-9519
Practice Address - Street 1:5129 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108
Practice Address - Country:US
Practice Address - Phone:605-332-2231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD144152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9201860Medicaid
SD9201860Medicaid
SD76517Medicare PIN