Provider Demographics
NPI:1750367827
Name:SLADE, C. LAWRENCE (MD)
Entity type:Individual
Prefix:DR
First Name:C.
Middle Name:LAWRENCE
Last Name:SLADE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3635 S. CLYDE MORRIS BLVD.
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-2349
Mailing Address - Country:US
Mailing Address - Phone:386-756-9400
Mailing Address - Fax:386-756-4338
Practice Address - Street 1:3635 S. CLYDE MORRIS BLVD
Practice Address - Street 2:400
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-2349
Practice Address - Country:US
Practice Address - Phone:386-756-9400
Practice Address - Fax:386-756-4338
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-20
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0040228174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL64490Medicare ID - Type Unspecified
FLD64550Medicare UPIN