Provider Demographics
NPI:1003926866
Name:STARK, RONALD J (DC)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:J
Last Name:STARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25610 SAGO PALM
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78261
Mailing Address - Country:US
Mailing Address - Phone:210-722-9565
Mailing Address - Fax:
Practice Address - Street 1:25610 SAGO PALM
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78261
Practice Address - Country:US
Practice Address - Phone:210-722-9565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004801111N00000X
TX11335111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
950255003Medicare UPIN
0255003Medicare ID - Type Unspecified