Provider Demographics
NPI:1003894262
Name:STARK, HEATHER (MD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:STARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20306 BADGER LANE
Mailing Address - Street 2:
Mailing Address - City:ONLEY
Mailing Address - State:VA
Mailing Address - Zip Code:23418
Mailing Address - Country:US
Mailing Address - Phone:757-787-7374
Mailing Address - Fax:757-787-4513
Practice Address - Street 1:20306 BADGER LANE
Practice Address - Street 2:
Practice Address - City:ONLEY
Practice Address - State:VA
Practice Address - Zip Code:23418
Practice Address - Country:US
Practice Address - Phone:757-787-7374
Practice Address - Fax:757-787-4513
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101050794207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G16733Medicare UPIN