Provider Demographics
NPI:1992788160
Name:SLATER, JONATHAN (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:SLATER
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:PO BOX 70266
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01107-0266
Mailing Address - Country:US
Mailing Address - Phone:413-733-9666
Mailing Address - Fax:413-750-3432
Practice Address - Street 1:100 WASON AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1381
Practice Address - Country:US
Practice Address - Phone:413-733-9666
Practice Address - Fax:413-750-3432
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA81014207RN0300X
CT032013207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA64747OtherFALLON
MA3137651Medicaid
MA10252OtherHARVARD PILGRIM
MA10252OtherHARVARD PILGRIM
MAQX7482Medicare PIN