Provider Demographics
NPI:1982613717
Name:SLACK, CHRISTOPHER LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:LEE
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 1:4632 S 25TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34981-5057
Mailing Address - Country:US
Mailing Address - Phone:772-464-9595
Mailing Address - Fax:772-464-9582
Practice Address - Street 1:4632 S 25TH ST
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34981-5057
Practice Address - Country:US
Practice Address - Phone:772-464-9595
Practice Address - Fax:772-464-9582
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME84369207YS0123X
CO36380207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264157700Medicaid
FL09061ZMedicare ID - Type Unspecified
FL264157700Medicaid