Provider Demographics
NPI:1255354783
Name:SLATE, RICHARD KENDRICK (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:KENDRICK
Last Name:SLATE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1607
Mailing Address - Street 2:
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-1607
Mailing Address - Country:US
Mailing Address - Phone:951-303-3391
Mailing Address - Fax:951-346-3627
Practice Address - Street 1:8700 BEVERLY BLVD
Practice Address - Street 2:CS-OCC
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90048-1804
Practice Address - Country:US
Practice Address - Phone:310-423-1155
Practice Address - Fax:310-659-3928
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG44344208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF19072Medicare UPIN