Provider Demographics
NPI:1235142316
Name:STARK, GEROLD J (MD)
Entity Type:Individual
Prefix:
First Name:GEROLD
Middle Name:J
Last Name:STARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3901 PINE LAKE RD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-5497
Mailing Address - Country:US
Mailing Address - Phone:402-421-3240
Mailing Address - Fax:402-423-0739
Practice Address - Street 1:3901 PINE LAKE RD
Practice Address - Street 2:SUITE 220
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-5497
Practice Address - Country:US
Practice Address - Phone:402-421-3240
Practice Address - Fax:402-423-0739
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2021-03-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NE22793207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G76074Medicare UPIN
NE277934Medicare PIN