Provider Demographics
NPI:1972748796
Name:DAVID P SLACK, MD INC.
Entity Type:Organization
Organization Name:DAVID P SLACK, MD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:P
Authorized Official - Last Name:SLACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-495-0971
Mailing Address - Street 1:9555 CHESAPEAKE DR # 204
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-6301
Mailing Address - Country:US
Mailing Address - Phone:858-495-0971
Mailing Address - Fax:858-495-0991
Practice Address - Street 1:9555 CHESAPEAKE DR # 204
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-6301
Practice Address - Country:US
Practice Address - Phone:858-495-0971
Practice Address - Fax:858-495-0991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-08
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG36344207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG36344Medicare PIN