Provider Demographics
NPI:1558346262
Name:STARK, KENNETH E (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:E
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 1:1613 BANNING BEACH RD
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-2024
Mailing Address - Country:US
Mailing Address - Phone:352-343-7735
Mailing Address - Fax:352-343-7740
Practice Address - Street 1:1613 BANNING BEACH RD
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-2024
Practice Address - Country:US
Practice Address - Phone:352-343-7735
Practice Address - Fax:352-343-7740
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL045588207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL370164600Medicaid
FLA59929Medicare UPIN
FL370164600Medicaid