Provider Demographics
NPI:1093741092
Name:STORK, DONALD E (DO)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:E
Last Name:STORK
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:7905 CALUMET AVE
Mailing Address - Street 2:HAMMOND CLINIC LLC
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-1215
Mailing Address - Country:US
Mailing Address - Phone:219-836-7214
Mailing Address - Fax:219-924-8794
Practice Address - Street 1:7905 CALUMET AVE
Practice Address - Street 2:HAMMOND CLINIC LLC
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1215
Practice Address - Country:US
Practice Address - Phone:219-836-7214
Practice Address - Fax:219-924-8794
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN02001336A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INE39197Medicare UPIN
IN473060E7Medicare ID - Type Unspecified