Provider Demographics
NPI:1326155292
Name:STAAB, DAVID BERNARD (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:BERNARD
Last Name:STAAB
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:DEPT 888067
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37995-8067
Mailing Address - Country:US
Mailing Address - Phone:865-588-8838
Mailing Address - Fax:
Practice Address - Street 1:576 FORT LOUDOUN MEDICAL CENTER DR
Practice Address - Street 2:#101
Practice Address - City:LENOIR CITY
Practice Address - State:TN
Practice Address - Zip Code:37772-5676
Practice Address - Country:US
Practice Address - Phone:865-690-5263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD35862208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3870535Medicaid
TN3870535Medicare ID - Type Unspecified
TN3870535Medicaid