Provider Demographics
NPI:1023085552
Name:STAKE, TERRY L (MD)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:L
Last Name:STAKE
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:PO BOX 5307
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45802-5307
Mailing Address - Country:US
Mailing Address - Phone:419-224-5707
Mailing Address - Fax:419-229-0040
Practice Address - Street 1:1 MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-6379
Practice Address - Country:US
Practice Address - Phone:304-243-3270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV143132085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV300117903OtherRAILROAD MEDICARE
WV0117198000Medicaid
WV000864293OtherMT STATE BCBS
OH300040909OtherRAILROAD MEDICARE
14313AOtherHEALTH PLAN OF UPPER OH V
OH0222011Medicaid
WV0641223Medicare PIN
WV300117903OtherRAILROAD MEDICARE
OH300040909OtherRAILROAD MEDICARE