MEDICARE: DR. LARRY VICTOR STAKER MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	150350-1205	UT

General Provider Information

NPI Number	:	1245315191
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARRY VICTOR STAKER MD

Provider Business Mailing Address
First Line	:	60 E SOUTH TEMPLE
Second Line	:	EAGLE GATE PLAZA, 3RD FLOOR
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84111-1004
Country	:	US
Telephone Number	:	801-578-5882
Fax Number	:

Provider Business Practice Location Address
First Line	:	60 E SOUTH TEMPLE
Second Line	:	EAGLE GATE PLAZA, 3RD FLOOR
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84111-1004
Country	:	US
Telephone Number	:	801-578-5882
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	07/08/2007

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