Provider Demographics
NPI:1457398711
Name:STATON, ROBERT DENNIS (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:DENNIS
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 1:3001 BOHNET BLVD N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-1726
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1010 32ND AVE S
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-5001
Practice Address - Country:US
Practice Address - Phone:218-233-7524
Practice Address - Fax:218-233-8627
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN252122084P0800X
ND41692084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN099398100Medicaid
MN59200STOtherBLUE SHIELD OF MINNESOTA
ND1455906Medicaid
MN116458OtherUCARE MINNESOTA
MN1010543OtherPREFERREDONE
MND26314Medicare UPIN
MN260002301Medicare ID - Type Unspecified