Provider Demographics
NPI:1376808485
Name:LAIES, SLAVITA MARIA (MD)
Entity type:Individual
Prefix:DR
First Name:SLAVITA
Middle Name:MARIA
Last Name:LAIES
Suffix:
Gender:F
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-468-8076
Mailing Address - Fax:239-468-7938
Practice Address - Street 1:632 DEL PRADO BLVD N STE 1
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-2278
Practice Address - Country:US
Practice Address - Phone:239-468-8076
Practice Address - Fax:239-468-7938
Is Sole Proprietor?:No
Enumeration Date:2012-07-05
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD171761207R00000X, 208M00000X
CAA145021207R00000X
FLME122906207RE0101X
NMMD2020-0591390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORMD171761OtherOREGON LICENSE
FL124222700Medicaid
ORFL5441085OtherDEA