Basic Information
| Provider Information | |||||||||
| NPI: | 1952864027 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SLACK | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | HOGAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 BODIN CIRCLE | ||||||||
| Address2: | INTERNAL MEDICINE CLINIC | ||||||||
| City: | FAIRFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074233000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 BODIN CIRCLE | ||||||||
| Address2: | INTERNAL MEDICINE CLINIC | ||||||||
| City: | FAIRFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074233000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2019 | ||||||||
| LastUpdateDate: | 06/30/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 176336 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.