Provider Demographics
NPI:1952864027
Name:SLACK, DANIEL HOGAN (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:HOGAN
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 1:101 BODIN CIRCLE
Mailing Address - Street 2:INTERNAL MEDICINE CLINIC
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533
Mailing Address - Country:US
Mailing Address - Phone:707-423-3000
Mailing Address - Fax:
Practice Address - Street 1:101 BODIN CIRCLE
Practice Address - Street 2:INTERNAL MEDICINE CLINIC
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533
Practice Address - Country:US
Practice Address - Phone:707-423-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-07
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA176336207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program