Provider Demographics
NPI:1558582304
Name:STARK, MICHAEL A (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:STARK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1808 VERDUGO BLVD.
Mailing Address - Street 2:SUITE 313
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-1463
Mailing Address - Country:US
Mailing Address - Phone:818-952-6183
Mailing Address - Fax:818-952-3603
Practice Address - Street 1:1808 VERDUGO BLVD.
Practice Address - Street 2:SUITE 313
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-1463
Practice Address - Country:US
Practice Address - Phone:818-952-6183
Practice Address - Fax:818-952-3603
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG33213207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G332130Medicaid
CA00G332130Medicaid
CAA45462Medicare UPIN