Provider Demographics
NPI:1699763821
Name:STAVER, ROBERT A (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:STAVER
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 1:1715 E 12TH ST
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3136
Mailing Address - Country:US
Mailing Address - Phone:541-296-2294
Mailing Address - Fax:
Practice Address - Street 1:1715 E 12TH ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3136
Practice Address - Country:US
Practice Address - Phone:541-296-2294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2007-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD09164207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR181271Medicaid
WA8299703Medicaid
OR181271Medicaid
R00WCJGHCMedicare PIN
R0000WCJGHMedicare PIN