Provider Demographics
NPI:1932429602
Name:SLACK, MELANIE PATRICE (MD)
Entity type:Individual
Prefix:DR
First Name:MELANIE
Middle Name:PATRICE
Last Name:SLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:MELANIE
Other - Middle Name:PATRICE
Other - Last Name:KOLPAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1694 WATER TOWER WAY STE 104
Mailing Address - Street 2:
Mailing Address - City:FOREST HILL
Mailing Address - State:MD
Mailing Address - Zip Code:21050-1776
Mailing Address - Country:US
Mailing Address - Phone:410-307-4568
Mailing Address - Fax:949-703-7304
Practice Address - Street 1:1694 WATER TOWER WAY STE 104
Practice Address - Street 2:
Practice Address - City:FOREST HILL
Practice Address - State:MD
Practice Address - Zip Code:21050-1776
Practice Address - Country:US
Practice Address - Phone:410-307-4568
Practice Address - Fax:949-703-7304
Is Sole Proprietor?:No
Enumeration Date:2010-06-04
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC7-0004578207Q00000X
DEC1-0010354207Q00000X
390200000X
MDDS0080767207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program