Provider Demographics
NPI:1154826709
Name:STARK, NICHOLAS RAYMOND (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:RAYMOND
Last Name:STARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:NICHOLAS
Other - Middle Name:RAYMOND
Other - Last Name:STUKEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:505 PARNASSUS AVE RM M24
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-2204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:505 PARNASSUS AVE RM M24
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2204
Practice Address - Country:US
Practice Address - Phone:415-206-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA166949207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program