Provider Demographics
NPI:1407828106
Name:STARK, JARED W (MD)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:W
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 1:455 S LIVERNOIS RD
Mailing Address - Street 2:STE C14
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307
Mailing Address - Country:US
Mailing Address - Phone:248-656-0070
Mailing Address - Fax:248-656-1963
Practice Address - Street 1:455 S LIVERNOIS RD
Practice Address - Street 2:STE C14
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307
Practice Address - Country:US
Practice Address - Phone:248-656-0070
Practice Address - Fax:248-656-1963
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJS030201208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics