1710927769 NPI number — DR. JOHN STARK MD

Table of content: DR. JOHN STARK MD (NPI 1710927769)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710927769 NPI number — DR. JOHN STARK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STARK
Provider First Name:
JOHN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710927769
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9746
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04104-5040
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-791-3888
Provider Business Mailing Address Fax Number:
207-828-7850

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
161 CORPORATE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTSMOUTH
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03801-6825
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-431-5154
Provider Business Practice Location Address Fax Number:
603-430-5033
Provider Enumeration Date:
06/07/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  9824 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)