Provider Demographics
NPI:1073689253
Name:SLACK, JAMES W (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:W
Last Name:SLACK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2101 EAST JEFFERSON STREET
Mailing Address - Street 2:PPQA MEDICARE COMPLIANCE UNIT 6 WEST ATTN THERESA BROOK
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:301-816-6308
Practice Address - Street 1:12255 FAIR LAKES PARKWAY
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-3952
Practice Address - Country:US
Practice Address - Phone:703-934-5820
Practice Address - Fax:703-934-5290
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
DCMD15560207W00000X
MDD0054382207W00000X
VA0101229044207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
006327M92Medicare ID - Type Unspecified
F05820Medicare UPIN