Provider Demographics
NPI:1114922994
Name:STARK, JEFFREY M (DPM)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:M
Last Name:STARK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 DUNCAN PL
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-1306
Mailing Address - Country:US
Mailing Address - Phone:516-764-3500
Mailing Address - Fax:516-536-4236
Practice Address - Street 1:1 DUNCAN PL
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-1306
Practice Address - Country:US
Practice Address - Phone:516-764-3500
Practice Address - Fax:516-536-4236
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-17
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNOO3165-1213EP1101X
NYN003165-1213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery