Provider Demographics
NPI:1073693412
Name:STARK, ANN (MD)
Entity Type:Individual
Prefix:
First Name:ANN
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 1:3601 TVC
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37232-0001
Mailing Address - Country:US
Mailing Address - Phone:615-322-3000
Mailing Address - Fax:
Practice Address - Street 1:330 BROOKLINE AVE # ROSE3
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215
Practice Address - Country:US
Practice Address - Phone:617-667-3276
Practice Address - Fax:617-667-7040
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL89642080N0001X
TNMD479552080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164973301Medicaid
E02012Medicare UPIN
TX164973301Medicaid