Provider Demographics
NPI:1275995391
Name:STARK, TIMOTHY WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:WILLIAM
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 1:800 ROSE ST
Mailing Address - Street 2:MN-283
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-7001
Mailing Address - Country:US
Mailing Address - Phone:859-232-5057
Mailing Address - Fax:859-257-6024
Practice Address - Street 1:800 ROSE ST
Practice Address - Street 2:MN-283
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-7001
Practice Address - Country:US
Practice Address - Phone:859-232-5057
Practice Address - Fax:859-257-6024
Is Sole Proprietor?:No
Enumeration Date:2016-03-28
Last Update Date:2017-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR4182208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology