Provider Demographics
NPI:1699160598
Name:SLACK, SEAN DAMIAN (DO)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:DAMIAN
Last Name:SLACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 571117
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84157-1117
Mailing Address - Country:US
Mailing Address - Phone:801-507-9700
Mailing Address - Fax:801-585-0603
Practice Address - Street 1:DIVISION OF EMERGENCY MEDICINE SCHOOL OF
Practice Address - Street 2:30 N 1900 E 1C026
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0001
Practice Address - Country:US
Practice Address - Phone:801-581-2730
Practice Address - Fax:801-585-0603
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-30
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCS65216207P00000X
390200000X
UT10104232-1204207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program