Provider Demographics
NPI:1073851481
Name:LARRY D. STARK, D.O., P.C.
Entity Type:Organization
Organization Name:LARRY D. STARK, D.O., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:STARK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:602-866-1501
Mailing Address - Street 1:3201 W PEORIA AVE
Mailing Address - Street 2:#A100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-4608
Mailing Address - Country:US
Mailing Address - Phone:602-866-1501
Mailing Address - Fax:602-866-2216
Practice Address - Street 1:3201 W PEORIA AVE
Practice Address - Street 2:#A100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-4608
Practice Address - Country:US
Practice Address - Phone:602-866-1501
Practice Address - Fax:602-866-2216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-18
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1754207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZE20681Medicare UPIN
AZZ155744Medicare UPIN