Provider Demographics
NPI:1073780441
Name:SLATER, MISTY D (MD)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:D
Last Name:SLATER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:D
Other - Last Name:JACOBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:482 INTERSTATE DR
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37355-3485
Mailing Address - Country:US
Mailing Address - Phone:931-728-4718
Mailing Address - Fax:931-728-1016
Practice Address - Street 1:482 INTERSTATE DR
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355-3485
Practice Address - Country:US
Practice Address - Phone:931-728-4718
Practice Address - Fax:931-728-1016
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2025-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35207Q00000X
ALMD.38961207Q00000X
IN01065155A207Q00000X
TN53750207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN048580O5Medicare PIN