Basic Information
| Provider Information | |||||||||
| NPI: | 1720100803 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SLATER | ||||||||
| FirstName: | JARED | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100286 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326100286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522650761 | ||||||||
| FaxNumber: | 3522651060 | ||||||||
| Practice Location | |||||||||
| Address1: | 1451 EL CAMINO REAL | ||||||||
| Address2: | |||||||||
| City: | THE VILLAGES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321590041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522650761 | ||||||||
| FaxNumber: | 3522651060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2007 | ||||||||
| LastUpdateDate: | 03/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 49862 | MN | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | ME154203 | FL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | P00888769 | 01 | MN | MEDICARE, RAILROAD | OTHER | 024490000 | 05 | MN | MEDICAID |