Provider Demographics
NPI:1154576239
Name:SLADE, BRANDON JAMES (DPM)
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:JAMES
Last Name:SLADE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 BISHOP ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-4635
Mailing Address - Country:US
Mailing Address - Phone:805-543-7788
Mailing Address - Fax:805-543-7828
Practice Address - Street 1:1551 BISHOP ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4635
Practice Address - Country:US
Practice Address - Phone:805-543-7788
Practice Address - Fax:805-543-7828
Is Sole Proprietor?:No
Enumeration Date:2008-11-17
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4945213ES0103X
IN41000226A213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFH048ZOtherPTAN