Provider Demographics
NPI:1053698464
Name:STEPHEN GLENN SLADE MD PA
Entity type:Organization
Organization Name:STEPHEN GLENN SLADE MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DELFINA
Authorized Official - Middle Name:A
Authorized Official - Last Name:VILLEGAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-626-5544
Mailing Address - Street 1:3900 ESSEX LN
Mailing Address - Street 2:SUITE #101
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77027-5133
Mailing Address - Country:US
Mailing Address - Phone:713-626-5544
Mailing Address - Fax:713-626-7744
Practice Address - Street 1:3900 ESSEX LN
Practice Address - Street 2:SUITE 101
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77027-5133
Practice Address - Country:US
Practice Address - Phone:713-626-5544
Practice Address - Fax:713-626-7744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-14
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF7175207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB145212Medicare PIN