Provider Demographics
NPI:1720038151
Name:SLACK, CHARLES THORNTON (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:THORNTON
Last Name:SLACK
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 1:1405 PECAN HOLLOW TRL
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75070-9061
Mailing Address - Country:US
Mailing Address - Phone:972-562-7253
Mailing Address - Fax:214-509-0273
Practice Address - Street 1:1105 CENTRAL EXPY NORTH
Practice Address - Street 2:SUITE 370
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013
Practice Address - Country:US
Practice Address - Phone:214-495-6464
Practice Address - Fax:214-509-0273
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0267208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF92581Medicare UPIN
TX611796Medicare ID - Type UnspecifiedMEDICARE