Provider Demographics
NPI:1891884276
Name:STAKER, GERALD D (DC)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:D
Last Name:STAKER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:976 JOHN ADAMS PKWY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4049
Mailing Address - Country:US
Mailing Address - Phone:208-522-5546
Mailing Address - Fax:208-522-4777
Practice Address - Street 1:976 JOHN ADAMS PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4049
Practice Address - Country:US
Practice Address - Phone:208-522-5546
Practice Address - Fax:208-522-4777
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-706111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC-706-9OtherBLUE CROSS INSURANCE
IDC-706-9OtherBLUE CROSS INSURANCE