Provider Demographics
NPI:1245315191
Name:STAKER, LARRY VICTOR (MD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:VICTOR
Last Name:STAKER
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 1:60 E SOUTH TEMPLE
Mailing Address - Street 2:EAGLE GATE PLAZA, 3RD FLOOR
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-1004
Mailing Address - Country:US
Mailing Address - Phone:801-578-5882
Mailing Address - Fax:
Practice Address - Street 1:60 E SOUTH TEMPLE
Practice Address - Street 2:EAGLE GATE PLAZA, 3RD FLOOR
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1004
Practice Address - Country:US
Practice Address - Phone:801-578-5882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT150350-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C63447Medicare UPIN