Provider Demographics
NPI:1497051767
Name:SLACK, LAURA PAIGE (MD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:PAIGE
Last Name:SLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 FREDERICA RD
Mailing Address - Street 2:
Mailing Address - City:ST SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-2600
Mailing Address - Country:US
Mailing Address - Phone:305-778-7857
Mailing Address - Fax:
Practice Address - Street 1:1620 FREDERICA RD
Practice Address - Street 2:
Practice Address - City:ST SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-2600
Practice Address - Country:US
Practice Address - Phone:912-268-2103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-04
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME105733207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine