Provider Demographics
NPI:1376747113
Name:STAACK, JEFFREY BLAIR (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:BLAIR
Last Name:STAACK
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 1:5513 DOGWOOD RD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37918-4221
Mailing Address - Country:US
Mailing Address - Phone:865-689-2278
Mailing Address - Fax:
Practice Address - Street 1:341 TRANE DR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-6053
Practice Address - Country:US
Practice Address - Phone:865-588-0880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN44686207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology