Provider Demographics
NPI:1083241103
Name:STAAK, BRIAN PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:PATRICK
Last Name:STAAK
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 1:3551 ROGER BROOKE DR
Mailing Address - Street 2:
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:210-916-8666
Mailing Address - Fax:210-916-8712
Practice Address - Street 1:1100 WILFORD HALL LOOP BLDG 4554
Practice Address - Street 2:
Practice Address - City:JBSA LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78236-5638
Practice Address - Country:US
Practice Address - Phone:210-916-8666
Practice Address - Fax:210-916-8712
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101274302208D00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice