Basic Information
| Provider Information | |||||||||
| NPI: | 1043271893 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STAKER | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4500 S 4000 W | ||||||||
| Address2: | |||||||||
| City: | WEST VALLEY CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841206235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4358332572 | ||||||||
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| Practice Location | |||||||||
| Address1: | 28 OFFICER CIR | ||||||||
| Address2: | |||||||||
| City: | TOOELE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840746061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4358332572 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083X0100X | 5248029-1205 | UT | Y | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine |
No ID Information.