Provider Demographics
NPI:1356393623
Name:SLAGOWSKI, DAVID J (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:J
Last Name:SLAGOWSKI
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 1:1330 PRIMROSE LN
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-1879
Mailing Address - Country:US
Mailing Address - Phone:208-631-8529
Mailing Address - Fax:
Practice Address - Street 1:3499 E FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5848
Practice Address - Country:US
Practice Address - Phone:208-884-1362
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3442-35152W00000X
IDODP-1006152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805533400Medicaid
ID1593355Medicare ID - Type Unspecified
IDU67291Medicare UPIN