Provider Demographics
NPI:1043271893
Name:STAKER, MICHAEL L (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:STAKER
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 1:4500 S 4000 W
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-6235
Mailing Address - Country:US
Mailing Address - Phone:435-833-2572
Mailing Address - Fax:
Practice Address - Street 1:28 OFFICER CIR
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-6061
Practice Address - Country:US
Practice Address - Phone:435-833-2572
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5248029-12052083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine