Provider Demographics
NPI:1093087579
Name:STARK, JUSTIN MYLES (DO)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:MYLES
Last Name:STARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 746638
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6638
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:900 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-4368
Practice Address - Country:US
Practice Address - Phone:904-249-0335
Practice Address - Fax:904-390-7495
Is Sole Proprietor?:No
Enumeration Date:2012-01-31
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA075156207R00000X
FLOS19751207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine