Provider Demographics
NPI:1497816458
Name:BRETT STARK DPM PC
Entity Type:Organization
Organization Name:BRETT STARK DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:S
Authorized Official - Last Name:STARK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:334-466-1401
Mailing Address - Street 1:300 N DEAN RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:AUBURN
Mailing Address - State:AL
Mailing Address - Zip Code:36830-4404
Mailing Address - Country:US
Mailing Address - Phone:334-466-1401
Mailing Address - Fax:334-466-1433
Practice Address - Street 1:785 N DEAN RD
Practice Address - Street 2:SUITE 100
Practice Address - City:AUBURN
Practice Address - State:AL
Practice Address - Zip Code:36830-4033
Practice Address - Country:US
Practice Address - Phone:334-466-1401
Practice Address - Fax:334-466-1433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL225213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51503568OtherBCBS
AL480033606OtherRAILROAD MEDICARE
AL4318200001OtherMEDICARE
AL51503568OtherBCBS
K025Medicare PIN