Provider Demographics
NPI:1821300088
Name:SLEZAK, NATHAN ROBERT (OD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:ROBERT
Last Name:SLEZAK
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 1:829 W MAIN ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-1998
Mailing Address - Country:US
Mailing Address - Phone:989-732-6261
Mailing Address - Fax:989-732-1276
Practice Address - Street 1:829 W MAIN ST
Practice Address - Street 2:SUITE E
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-1998
Practice Address - Country:US
Practice Address - Phone:989-732-6261
Practice Address - Fax:989-732-1276
Is Sole Proprietor?:No
Enumeration Date:2010-07-05
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004573152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F9100OtherBLUE CROSS BLUE SHIELD
MI0F9100OtherBLUE CROSS BLUE SHIELD