Provider Demographics
NPI:1821291048
Name:SLATTERY, CHARLES A (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:SLATTERY
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 1:7455 S US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-8115
Mailing Address - Country:US
Mailing Address - Phone:321-264-2100
Mailing Address - Fax:321-264-2485
Practice Address - Street 1:7455 S US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-8115
Practice Address - Country:US
Practice Address - Phone:321-264-2100
Practice Address - Fax:321-264-2485
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0051997207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL04843OtherBLUE SHIELD
FL062108100Medicaid
FLME0051997OtherMEDICAL LICENSE
FL110165605OtherRAILROAD MEDICARE
FL110165605OtherRAILROAD MEDICARE
FL04843OtherBLUE SHIELD