Provider Demographics
NPI:1275593717
Name:STAKER, GREGORY L (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
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 1:210 W 300 N 75-3
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:UT
Mailing Address - Zip Code:84066
Mailing Address - Country:US
Mailing Address - Phone:435-722-3971
Mailing Address - Fax:435-722-6104
Practice Address - Street 1:210 W 300 N 75-3
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066
Practice Address - Country:US
Practice Address - Phone:435-722-3971
Practice Address - Fax:435-722-6104
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-27
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT49110821205207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000006166OtherMEDICARE GROUP PIN
UTD3854Medicaid
UT1068670001Medicare NSC
UTH37591Medicare UPIN
UT006166022Medicare PIN
UT000006166OtherMEDICARE GROUP PIN