Provider Demographics
NPI:1700110921
Name:SLATTERY, STEPHEN EDWARD (DO)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:EDWARD
Last Name:SLATTERY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10000 SE MAIN ST
Mailing Address - Street 2:SUITE 116
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2448
Mailing Address - Country:US
Mailing Address - Phone:503-251-6292
Mailing Address - Fax:
Practice Address - Street 1:17055 RUBEN LN
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:OR
Practice Address - Zip Code:97055-9276
Practice Address - Country:US
Practice Address - Phone:503-668-8002
Practice Address - Fax:503-668-5246
Is Sole Proprietor?:No
Enumeration Date:2009-09-21
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A11657207Q00000X
ORDO126175207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR191810Medicare PIN