Provider Demographics
NPI:1508989450
Name:STATON, BRENT DAVIS (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:DAVIS
Last Name:STATON
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 1:1135 S WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-5961
Mailing Address - Country:US
Mailing Address - Phone:931-400-0808
Mailing Address - Fax:931-400-0809
Practice Address - Street 1:1135 S WALNUT AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-5961
Practice Address - Country:US
Practice Address - Phone:931-400-0808
Practice Address - Fax:615-735-0008
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-07
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN45555207Q00000X, 207V00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist