Healthcare Provider Details

I. General information

NPI: 1659169902
Provider Name (Legal Business Name): JARED MATTHEW STATEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2025
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 MEDICAL CENTER RD
FORT CAVAZOS TX
76544-5060
US

IV. Provider business mailing address

590 MEDICAL CENTER ROAD BUILDING 36065
APO AA
76544
US

V. Phone/Fax

Practice location:
  • Phone: 254-288-8000
  • Fax:
Mailing address:
  • Phone: 254-288-8888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberBP10091432
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: