Provider Demographics
NPI:1487844395
Name:STAKE, SONI ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:SONI
Middle Name:ELIZABETH
Last Name:STAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 E EDNA AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2101
Mailing Address - Country:US
Mailing Address - Phone:313-570-1752
Mailing Address - Fax:
Practice Address - Street 1:100 E 5TH ST
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:AZ
Practice Address - Zip Code:85607-2859
Practice Address - Country:US
Practice Address - Phone:520-364-7659
Practice Address - Fax:520-364-8541
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ40468207R00000X, 208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ362117Medicaid
AZ362117Medicaid