Provider Demographics
NPI:1568541142
Name:T GAIL STARK DPM PA
Entity Type:Organization
Organization Name:T GAIL STARK DPM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:T
Authorized Official - Middle Name:GAIL
Authorized Official - Last Name:STARK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:850-497-8876
Mailing Address - Street 1:12385 SORRENTO RD
Mailing Address - Street 2:SUITE D-4
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32507-8664
Mailing Address - Country:US
Mailing Address - Phone:850-497-8876
Mailing Address - Fax:850-497-1721
Practice Address - Street 1:12385 SORRENTO RD
Practice Address - Street 2:SUITE D-4
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32507-8664
Practice Address - Country:US
Practice Address - Phone:850-497-8876
Practice Address - Fax:850-497-1721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2420213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1400157OtherGHI
FL5439096OtherAETNA
AL59138421OtherBLUE CROSS ALABAMA
AL59138421OtherBLUE CROSS ALABAMA
FL1400157OtherGHI