Provider Demographics
NPI:1194187963
Name:STARK, MATTHEW JORDAN (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JORDAN
Last Name:STARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 N MILITARY TRL STE 355
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-6312
Mailing Address - Country:US
Mailing Address - Phone:561-510-9150
Mailing Address - Fax:561-600-9655
Practice Address - Street 1:2600 N MILITARY TRL STE 355
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6312
Practice Address - Country:US
Practice Address - Phone:561-510-9150
Practice Address - Fax:561-600-9655
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1431812084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry