Provider Demographics
NPI:1467467399
Name:SLACK, ROBERT W (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:SLACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 N THANKSGIVING WYAY
Mailing Address - Street 2:STE 260
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-4158
Mailing Address - Country:US
Mailing Address - Phone:385-455-7170
Mailing Address - Fax:888-823-5887
Practice Address - Street 1:10968 N ALPINE HWY
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:UT
Practice Address - Zip Code:84003-8874
Practice Address - Country:US
Practice Address - Phone:801-763-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT53766721204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTH99102Medicare UPIN
UT005532647Medicare PIN
UT000063531Medicare PIN