Provider Demographics
NPI:1518520188
Name:STARK, ROBERT
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:STARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 39070
Mailing Address - Street 2:
Mailing Address - City:NINILCHIK
Mailing Address - State:AK
Mailing Address - Zip Code:99639-0070
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15765 KINGSLEY RD.
Practice Address - Street 2:
Practice Address - City:NINILCHIK
Practice Address - State:AK
Practice Address - Zip Code:99639
Practice Address - Country:US
Practice Address - Phone:907-420-4713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-18
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist